Calhoun v. Bisignano

UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF MARYLAND
KANJUETTE C., *
Plaintiff, *
v. * Civil Action No. EA-25-612
FRANK J. BISIGNANO, *
Commissioner of Social Security,1
*
Defendant.
*
MEMORANDUM OPINION
On February 24, 2025, Plaintiff Kanjuette C. petitioned this Court to review the final
decision of the Social Security Administration (SSA or Commissioner) denying her claim for
benefits. ECF No. 1. This case was referred to a United States Magistrate Judge with the
parties’ consent.2 28 U.S.C. § 636; Local Rule 301.4 (D. Md. Dec. 1, 2025). Pending before the
Court is Plaintiff’s appeal, which is fully briefed. ECF Nos. 13, 15. No hearing is necessary.
Local Rule 105.6. This Court must uphold the decision of the SSA if it is supported by
substantial evidence and if the SSA employed proper legal standards. 42 U.S.C. §§ 405(g),
1383(c)(3); Craig v. Chater, 76 F.3d 585, 589 (4th Cir. 1996). Under that standard, and for the
reasons set forth below, the Commissioner’s decision is reversed, and the case is remanded for
further proceedings consistent with this Memorandum Opinion.
1 Plaintiff filed this case against Leland Dudek, the Acting Commissioner of Social
Security, on February 24, 2025. ECF No. 1. On May 7, 2025, Frank J. Bisignano became the
Commissioner. See https://perma.cc/6HGN-DL7G (last visited Feb. 6, 2026). Accordingly,
Commissioner Bisignano has been substituted as Defendant in this case pursuant to Federal Rule
of Civil Procedure 25(d).
2 This case was reassigned to the undersigned on January 8, 2026.
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I. BACKGROUND
A. Procedural History
In 2021, Plaintiff filed an application for Disability Insurance Benefits under Title II of
the Social Security Act (the Act), 42 U.S.C. § 301 et seq., alleging a disability onset date of May
4, 2020.3 ECF No. 13 at 1; see also ECF No. 9-3 at 40.4 Plaintiff claims that she is disabled
within the meaning of the Act because she is unable to work due to congestive heart failure,
diabetes mellitus, hypertension, and a rotator cuff tear. ECF Nos. 13 at 1; 9-3 at 30; 9-9 at 2–6;
9-10 at 5. The SSA initially denied Plaintiff’s application for benefits on November 4, 2022.
ECF No. 9-8 at 9–10. On November 23, 2022, Plaintiff sought reconsideration, and the SSA
affirmed its initial denial. ECF No. 9-8 at 13–17. On May 30, 2023, Plaintiff requested a
hearing before an Administrative Law Judge (ALJ), which was held on March 5, 2024. ECF
Nos. 9-6 at 95–117; 9-8 at 18–19. The ALJ rendered a decision on May 22, 2024, in which the
ALJ found that Plaintiff was not disabled within the meaning of the Act. ECF No. 9-3 at 35–49.
On July 25, 2024, Plaintiff requested a review of the ALJ’s decision, which the Appeals Council
denied on October 24, 2024. ECF Nos. 9-3 at 9–11; 9-8 at 106–107; 9-10 at 118–128. The
ALJ’s May 22, 2024 decision therefore constitutes the final, reviewable decision of the SSA.
Sims v. Apfel, 530 U.S. 103, 106-107 (2000); 42 U.S.C. § 405(g); 20 C.F.R. § 422.210(a).
B. Statutory Framework
The Social Security Act authorizes disability insurance benefit payments to every insured
individual who “is under a disability.” Cleveland v. Policy Mgmt. Sys. Corp., 526 U.S. 795, 801
(1999) (quoting 42 U.S.C. § 423(a)(1)); see also Shue v. O’Malley, No. 23-1795, 2024 WL
3 Plaintiff’s application for benefits was not included in the administrative record. See
generally ECF No. 9.
4 Page numbers refer to the pagination of the Court’s Case Management/Electronic Case
Files (CM/ECF) system printed at the top of the cited document.
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2827936, at *3 (4th Cir. June 4, 2024). The Act defines disability as the “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).
Federal regulations require the ALJ to evaluate a claimant’s disability claim using a five-
step sequential evaluation process. 20 C.F.R. § 404.1520. Through this process, an ALJ
evaluates, in order, “whether the claimant: (1) worked during the alleged period of disability;
(2) had a severe impairment; (3) had an impairment that met or equaled the requirements of a
listed impairment; (4) could return to her past relevant work; and (5) if not, could perform any
other work in the national economy.” Hancock v. Astrue, 667 F.3d 470, 472 (4th Cir. 2012).
“The applicant bears the burden of production and proof during the first four steps of the
inquiry.” Pass v. Chater, 65 F.3d 1200, 1203 (4th Cir. 1995). At the fifth step, “the burden
shifts to the Commissioner to prove, by a preponderance of the evidence, that the claimant can
perform other work that exists in significant numbers in the national economy, considering the
claimant’s residual functional capacity, age, education, and work experience.” Mascio v. Colvin,
780 F.3d 632, 635 (4th Cir. 2015) (internal quotation marks and citation omitted).
If the claimant does not carry their burden at the third step of the sequential evaluation,
then the ALJ must assess relevant evidence and make a finding regarding the claimant’s residual
functional capacity. 20 C.F.R. § 404.1520(e); Monroe v. Colvin, 826 F.3d 176, 179 (4th Cir.
2016). Residual functional capacity is defined as “the most you can still do despite your
[physical and mental] limitations.” 20 C.F.R. § 404.1545. The residual functional capacity
assessment “must first identify the individual’s functional limitations or restrictions and assess
his or her work-related abilities on a function-by-function basis.” Mascio, 780 F.3d at 636
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(quoting Social Security Ruling 96-8p, Titles II and XVI: Assessing Residual Functional
Capacity in Initial Claims (SSR 96-8p), 61 Fed. Reg. 34,474, 34,475 (July 2, 1996)). “Only after
such a function-by-function analysis may an ALJ express [residual functional capacity] ‘in terms
of the exertional levels of work.’” Monroe, 826 F.3d at 187 (quoting Mascio, 780 F.3d at 636).
The ALJ then uses its residual functional capacity determination at the fourth and fifth steps of
the disability assessment. 20 C.F.R. § 404.1520(e); Monroe, 826 F.3d at 179.
C. The ALJ’s Decision
At step one of the five-step sequential disability evaluation, the ALJ found that Plaintiff
had not engaged in substantial gainful activity since the alleged disability onset date. ECF No. 9-
3 at 40. At step two, the ALJ found that Plaintiff suffered from the severe impairments of
“coronary artery disease, shoulder disorder, carpal tunnel syndrome, diabetes mellitus, and
obesity” and non-severe impairments of cervical spine disorder, depression, and anxiety. Id. at
41. At step three, the ALJ determined that Plaintiff “does not have an impairment or
combination of impairments that meets or medically equals the severity of one of the listed
impairments in 20 CFR Part 404, Subpart P, Appendix 1.” Id. at 43. Before continuing to the
fourth step of the sequential evaluation, the ALJ determined that Plaintiff retained the residual
functional capacity to:
perform light work as defined in 20 CFR 404.1567(b) with the
following limitations: She can tolerate no concentrated exposure to
temperature extremes or dust, fumes, or pulmonary irritants. She
can no more than frequently handle, finger, and feel. She can no
more than occasionally push, pull, or reach overhead.
Id. at 44. At the fourth step, the ALJ determined that Plaintiff can perform past relevant work as
a policyholder information clerk, appointment clerk, and insurance clerk. Id. at 48. Lastly, at the
fifth step, the ALJ determined Plaintiff had not been under a disability, as defined in the Social
Security Act, and the SSA properly denied her application for benefits. Id. at 49.
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II. DISCUSSION
On appeal, Plaintiff argues that the ALJ erroneously assessed (1) her non-severe mental
impairments, (2) medical opinion evidence, (3) her subjective statements, and (4) her residual
functional capacity. ECF No. 13 at 3–22. Each of these arguments, along with the applicable
standard of review, is addressed in turn below.
A. Standard of Review
The scope of judicial review of the SSA’s disability determination is “circumscribed.”
Britt v. Saul, 860 Fed. Appx. 256, 259 (4th Cir. 2021) (citing 42 U.S.C. § 405(g)). The Court
must affirm the decision “so long as the agency applied correct legal standards and the factual
findings are supported by substantial evidence.” Id.; accord Mascio, 780 F.3d at 634; Coffman
v. Bowen, 829 F.2d 514, 517 (4th Cir. 1987). Factual findings supported by substantial evidence
“shall be conclusive.” 42 U.S.C. § 405(g); see also Hays v. Sullivan, 907 F.2d 1453, 1456 (4th
Cir. 1990) (“[I]t is not within the province of a reviewing court to determine the weight of the
evidence, nor is it the court’s function to substitute its judgment for that of the Secretary if [the]
decision is supported by substantial evidence.”).
“The phrase ‘substantial evidence’ is a ‘term of art’ used throughout administrative law
to describe how courts are to review agency factfinding.” Biestek v. Berryhill, 587 U.S. 97, 102
(2019). Under this standard of review, substantial evidence “means—and means only—‘such
relevant evidence as a reasonable mind might accept as adequate to support a conclusion.’” Id.
at 103 (quoting Consolidated Edison Co. v. NLRB, 305 U.S. 197, 229 (1938)); see also Laws v.
Celebrezze, 368 F.2d 640, 642 (4th Cir. 1966) (“Substantial evidence . . . is evidence which a
reasoning mind would accept as sufficient to support a particular conclusion.”). It is “more than
a mere scintilla . . . [and] somewhat less than a preponderance.” Laws, 368 F.2d at 642. The
“threshold for such evidentiary sufficiency is not high.” Biestek, 587 U.S. at 103.
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In conducting the substantial evidence inquiry, this Court’s review is limited to whether
the ALJ analyzed the relevant evidence and sufficiently explained their findings and rationale in
crediting the evidence. Sterling Smokeless Coal Co. v. Akers, 131 F.3d 438, 439-440 (4th Cir.
1997). Although an ALJ’s decision must be sufficiently detailed to allow for meaningful judicial
review, an “elaborate or even sophisticated” explanation is not required. Mascio, 780 F.3d at
636-637; T-Mobile S., LLC v. City of Roswell, 574 U.S. 293, 302 (2015). Rather, an
administrative decision’s reasoning need only be “reasonably discernible.” Garland v. Ming
Dai, 593 U.S. 357, 369 (2021). “Meaningful review is frustrated—and remand necessary—only
where [the court is] unable to fathom the [ALJ’s] rationale in relation to evidence in the record.”
Britt, 860 Fed. Appx. at 262 (internal quotation marks and citation omitted).
B. Non-Severe Mental Impairments5
As explained above, an ALJ determines if a claimant suffers from a severe impairment at
step two of the disability evaluation. Hancock, 667 F.3d at 472. An impairment or combination
of impairments is severe if it “significantly limits [the claimant’s] physical or mental ability to do
basic work activities.” 20 C.F.R. § 404.1520(c). Federal regulations require an ALJ to evaluate
the severity of mental impairments by assessing limitations in four “paragraph B” functional
areas: (1) “understanding, remembering, or applying information”; (2) “interacting with others”;
(3) “concentrating, persisting, or maintaining pace”; and (4) “adapting, or managing oneself.”
Anthony M. v. Commissioner, Civil Action No. SAG-19-651, 2020 WL 434581, at *2-3 (D. Md.
Jan. 28, 2020) (citing 20 C.F.R. § 404.1520a). The severity determination at step two is distinct
from the assessment of residual functional capacity, which occurs after step three. See, e.g., id.
5 Plaintiff’s arguments regarding the ALJ’s evaluations of Plaintiff’s non-severe mental
impairment and medical opinions are embedded within her residual functional capacity
argument. ECF No. 13 at 6–8. For greater clarity, the undersigned addresses these arguments
separately.
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at *3 (explaining that “the limitations identified in the ‘paragraph B’ criteria are not [a residual
functional capacity] assessment but are used to rate the severity of mental impairments at steps 2
and 3 of the sequential evaluation process”) (internal quotations and citations omitted).
When formulating a residual functional capacity assessment, an ALJ “must consider all
the claimant’s ‘physical and mental impairments, severe and otherwise, and determine, on a
function-by-function basis, how they affect [the claimant’s] ability to work.’” Thomas v.
Berryhill, 916 F.3d 307, 311 (4th Cir. 2019) (quoting Monroe, 826 F.3d at 188) (alteration in
original); see also SSR 96-8p, 1996 WL 374184, at *5 (stating that an ALJ must consider the
“limitations and restrictions imposed by all of an individual’s impairments, even those that are
not severe,” when assessing a claimant’s residual functional capacity). Remand is appropriate
where an ALJ finds an impairment non-severe at step two but then fails to consider its potential
functional effects when assessing the claimant’s residual functional capacity. E.g., Janet L. v.
Saul, Civil Action No. CBD-19-2544, 2021 WL 1733469, at *6 (D. Md. Apr. 30, 2021)
(remanding where “[a]lthough the Court found that the ALJ provided sufficient analysis to
explain his conclusions that Plaintiff’s impairments are non-severe at step two, the ALJ failed to
consider Plaintiff’s non-severe impairments throughout the sequential evaluation, as required by
the Regulations”).
Plaintiff contends that the residual functional capacity determination lacks the
explanation required by the regulations because the ALJ did not impose specific functional
restrictions or address why such restrictions were unnecessary. ECF No. 13 at 6–8. The
Commissioner responds that “if an ALJ finds that a limitation is minimal or negligible . . . it is
not error to decline to assess a resultant functional limitation.” ECF No. 15 at 8. The
Commissioner argues that “an ALJ need only support such a finding with a ‘brief’ discussion of
evidence related to mental impairments that would support the ALJ’s finding that no mental
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[residual functional capacity] restriction is warranted.” Id. (citing Kenneth C. v. Kijakazi, Civil
Action No. BAH-22-2936, 2023 WL 5721641, at *4 (D. Md. Sep. 5, 2023)).
At step two, the ALJ evaluated the severity of Plaintiff’s mental impairments by
assessing her limitations in the four “paragraph B” functional areas. ECF No. 9-3 at 41–42. The
ALJ found that Plaintiff had mild limitations in all four functional areas. Id. Specifically, the
ALJ noted that Plaintiff needed reminders to take medication, interacted with others infrequently,
experienced anxiety in crowded places, had difficulty performing some calculations, slept
poorly, and reported difficulty handling stress and changes in routine. Id. The ALJ further
acknowledged diagnoses of “adjustment disorder with mixed anxiety and depressed mood.” Id.
at 42. The ALJ stated that the clinical findings were consistent with “mild to moderate
depression.” Id. The ALJ ultimately concluded that these impairments were non-severe
because, when “considered singly and in combination,” they did not cause more than “minimal
limitation in the claimant’s ability to perform basic mental work activities.” Id. at 42. The ALJ
expressly recognized, however, that his paragraph B findings “are not a residual functional
capacity assessment” and that the residual functional capacity determination at steps four and
five required “a more detailed assessment.” Id. Despite this acknowledgment, the decision
contains no such assessment. After concluding that Plaintiff’s mental impairments were non-
severe, the ALJ did not discuss whether Plaintiff’s mild limitations resulted in any work-related
functional restrictions, nor explain why none were warranted.
The only discussion of Plaintiff’s mental impairments after step two appears in the ALJ’s
summary of two medical opinions. Id. at 47–48. The ALJ briefly summarized the November 4,
2022 opinion of a reviewing psychologist, who found Plaintiff’s mental impairments were non-
severe. Id. at 47; ECF No. 9-7 at 4–5. The ALJ deemed this opinion persuasive because it was
consistent with the record. ECF No. 9-3 at 47. The ALJ also summarized an October 26, 2022
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consultative psychological evaluation, which found that “depressive symptoms likely contributed
to [Plaintiff’s] inability to work.” Id. at 48; ECF No. 9-14 at 69. The ALJ found that opinion
unpersuasive because it was not consistent with evidence in the record as a whole. ECF No. 9-3
at 48. These summaries do not constitute the “more detailed assessment” the ALJ acknowledged
was required, as they address only whether Plaintiff’s mental impairments were present or
severe, an issue the ALJ had already addressed at step two. E.g., Payton v. Colvin, Civil Action
No. JKS 13-2034, 2014 WL 4182339, at *4 (D. Md. Aug. 20, 2014) (“Thus, while the failure to
address [Plaintiff’s] depression at step two is not necessarily reversible error, it became so when
the ALJ failed to consider the mental impairment in his [residual functional capacity]
assessment, as required by 20 C.F.R § 404.1520a (d)(3)”).
The residual functional capacity assessment requires the ALJ to evaluate whether
Plaintiff’s mental impairments call for any work-related functional limitations, and, if not, to
explain why none are warranted. Eiker v. Astrue, Civil Action No. CBD-11-3584, 2013 WL
2149755, at *8 (D. Md. May 15, 2013) (finding that the ALJ did not address claimant’s alleged
limitations caused by bipolar disorder and did not explain how these limitations lead to the
conclusion that claimant can perform work in two-hour increments). The Commissioner
correctly notes that a brief discussion would be sufficient to explain why no residual functional
capacity restriction is warranted based on the evidence. ECF No. 15 at 8. Here, however, there
was no discussion at all, which necessitates remand. E.g., Janet L., 2021 WL 1733469, at *8
(“Failure by the ALJ to consider a claimant’s non-severe impairments at subsequent steps of the
[residual functional capacity] analysis requires remand.”) (collecting cases).
C. Medical Opinions
An ALJ “must follow certain procedures when assessing the weight to which medical
opinions are entitled” and “articulate . . . how persuasive [the ALJ] finds each medical opinion.”
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Adrianna S. v. Commissioner, Soc. Sec. Admin., Civil Action No. SAG-20-3136, 2022 WL
112034, at *1 (D. Md. Jan. 12, 2022) (citing 20 C.F.R. §§ 404.1520c, 404.1520c(b)). The
implementing regulations identify a series of factors that the SSA must consider when assessing
medical opinions. 20 C.F.R. § 404.1520c(c). Among those factors, “[s]upportability and
consistency are the most important factors when considering the persuasiveness of medical
opinions.” Adrianna S., 2922 WL 112034, at *1; see also 20 C.F.R. § 404.1520c(b)(2).
“Supportability generally refers to ‘the objective medical evidence and supporting explanations
provided by a medical source.’” Adrianna S., 2022 WL 112034, at *1 (quoting 20 C.F.R.
§ 404.1520c(c)(1)). “Strictly speaking, ‘supportability’ concerns an opinion’s reference to
diagnostic techniques, data collection procedures/analysis, and other objective medical
evidence.” Carlos F. v. Kijakazi, Civil Action No. BAH-22-2049, 2023 WL 3293086, at *3 (D.
Md. May 5, 2023) (internal quotation marks and citation omitted) (quoting 20 C.F.R.
§ 404.1520c(c)(1)). “In assessing consistency, the ALJ looks to the degree of cohesion between
the medical opinion and ‘the evidence from other medical sources and nonmedical sources in the
claim.’” Andrew P. v. O’Malley, Civil Action No. CDA-23-2443, 2024 WL 4288063, at *3 (D.
Md. Sept. 25, 2024) (quoting Adrianna S., 2022 WL 112034, at *1); see also 20 C.F.R.
§ 404.1520c(c)(2). “Supportability and consistency ‘must be considered independently.’”
Antwoin W. v. Dudek, Civil Action No. CDA-24-75, 2025 WL 949410, at *3 (D. Md. Mar. 28,
2025) (quoting Carlos F., 2023 WL 3293086, at *3).
Remand is warranted when an ALJ fails to properly consider the supportability of a
medical opinion. E.g., Lauren P. v. Dudek, Civil Action No. SAG-24-0480, 2025 WL 754522,
at *5 (D. Md. Mar. 10, 2025) (collecting cases). Accordingly, an ALJ must “explain how [they]
considered the supportability and consistency factors for a medical source’s medical opinions.”
20 C.F.R. § 404.1520c(b)(2). This explanation must include reference to specific evidence in the
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record. Shelley C. v. Commissioner of Soc. Sec. Admin., 61 F.4th 341, 358 (4th Cir. 2023).
Importantly, for “the ALJ to have adequately discussed the supportability of . . . opinions, the
ALJ needed to evaluate what the [physicians] said they based their opinion on—not simply how
their opinions compared to the record evidence as a whole, which only goes to . . . consistency.”
Carlos F., 2023 WL 3293086, at *3 (quoting Mary W. v. Commissioner of Soc. Sec., Civ. No.
20-5523, 2022 WL 202764, at *10 (S.D. Ohio Jan. 24, 2022)) (alteration in original).
Plaintiff argues that the ALJ failed to properly evaluate the supportability of the October
21, 2022 medical opinion of consultative examiner Anuja Kurichh, M.D. ECF Nos. 13 at 13–15;
9-14 at 55–64. The Commissioner contends that the ALJ relied “on the entire record, not
singular pieces of evidence” to find Dr. Kurichh’s opinion unpersuasive and that the ALJ’s
decision is therefore supported by substantial evidence. ECF No. 15 at 17–19. Dr. Kurichh’s
October 24, 2022 examination of the Plaintiff showed a
limited range of motion in cervical spine, lumbar spine, both
shoulders, both hips, limited supine straight leg raise, normal gait
with no assistive device, tenderness to palpation of her bilateral
trapezius and paraspinal muscles, slightly decreased strength in her
right grip and upper extremity, normal sensation, normal deep
tendon reflexes, intact cranial nerves.
ECF Nos. 9-3 at 48; 9-14 at 55–62. Dr. Kurichh opined that Plaintiff’s “ability to do work
related activities such as prolonged sitting, standing, and walking is limited due to low-back
pain, abdominal spasm, fatigue, [and] shortness of breath” and that “[s]he cannot lift and carry
any weight more than 5 [pounds] for [a] short time or short distance only.” ECF No. 9-14 at 62.
The ALJ found Dr. Kurichh’s opinion unpersuasive because it was
not entirely consistent with the evidence in the record as a whole,
which showed that she is stable from a cardiac standpoint with her
sternal chest wound noted to be completely healed, that her diabetes
is under improving control with normal sensation noted in her
extremities, and that she has had little treatment for her carpal tunnel
syndrome or her shoulder disorder.
ECF No. 9-3 at 48.
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In Carlos F., this Court held that the ALJ had failed to address the supportability factor
where the ALJ deemed the examiner’s opinion unsupported solely because it conflicted with
prior assessments, without evaluating whether the examiner’s own explanations and cited
evidence supported the opinion. 2023 WL 3293086 at *4. Here, the Commissioner’s defense of
the ALJ’s supportability analysis similarly conflates the consistency and supportability factors.
Although the ALJ acknowledged that that Dr. Kurichh’s opinion was supported by examination
findings, the decision did not evaluate whether, or explain how, those findings supported Dr.
Kurichh’s opinion. ECF No. 9-3 at 48. Instead, the ALJ relied on evidence elsewhere in the
record that allegedly conflicted with Dr. Kurichh’s conclusions without addressing the
“diagnostic techniques, data collection procedures/analysis, and other objective medical
evidence” underlying her opinion. Carlos F., 2023 WL 3293086, at *3. As in Carlos F., the
ALJ’s failure to evaluate the opinion’s internal support renders the ALJ’s supportability analysis
legally insufficient.
The Commissioner further argues, relying on Janowsky v. Berryhill, that the ALJ
permissibly discounted Dr. Kurichh’s opinion because Dr. Kurichh used vague terms. ECF No.
15 at 18; No. 7:17-CV-246-D, 2018 WL 6710240, at *7-8 (E.D.N.C. Nov. 19, 2018), report and
recommendation adopted sub nom., 2018 WL 6706678 (E.D.N.C. Dec. 20, 2018). That reliance
is misplaced. The Janowsky court upheld the ALJ’s decision to discount the examiner’s opinion
because the ALJ conducted the required consistency and supportability analyses. 2018 WL
6710240, at *7-8. The ALJ identified specific inconsistencies in the record and explained that
the examiner’s own test results did not support the conclusions reached. Id. Although the ALJ
also noted that the opinion used vague language and imposed ambiguous restrictions, vagueness
was not the sole basis for assigning little weight to the opinion. Id. Rather, it was cited in
addition to, not as a substitute for, the required consistency and supportability analyses. Id.
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Here, unlike in Janowsky, the ALJ did not meaningfully evaluate whether Dr. Kurichh’s
examination findings supported her opinion. Accordingly, the ALJ’s evaluation of the medical
opinion remains legally deficient from a supportability analysis standpoint regardless of whether
the medical opinion was vague as the Commissioner suggests.
D. Subjective Statements
When evaluating a claimant’s subjective symptoms, an ALJ is required to use the two-
step framework set forth in 20 C.F.R. § 404.1529 and Social Security Ruling 16-3p, Titles II and
XVI: Evaluation of Symptoms in Disability Claims (SSR 16-3p), 2016 WL 1119029 (SSA Mar.
16, 2016). Arakas v. Commissioner, Soc. Sec. Admin., 983 F.3d 83, 95 (4th Cir. 2020). Under
this framework, the ALJ must first “determine whether objective medical evidence presents a
‘medically determinable impairment’ that could reasonably be expected to produce the
claimant’s alleged symptoms.” Id. (quoting 20 C.F.R. § 404.1529(b); SSR 16-3p, 2016 WL
1119029, at *3). Second, the ALJ must “evaluate the intensity and persistence of those
symptoms to determine the extent to which the symptoms limit an individual’s ability to perform
work-related activities.” SSR 16-3p, 2016 WL 1119029, at *2; see also Arakas, 983 F.3d at 95;
20 C.F.R. § 404.1529(c). Importantly, “[a]t this step, objective evidence is not required to find
the claimant disabled.” Arakas, 983 F.3d at 95 (emphasis in original).
Consideration of the intensity, persistence, and limiting effects of symptoms requires the
ALJ to examine the entire record, including the objective medical evidence; the claimant’s
statements about the intensity, persistence, and limiting effects of symptoms; statements and
other information provided by medical sources and other persons; and any other relevant
evidence in the case record. 20 C.F.R. § 404.1529(c); SSR 16-3p, 2016 WL 1119029, at *4–7.
The ALJ may also consider factors such as daily activities; the location, duration, frequency, and
intensity of pain or other symptoms; factors that precipitate and aggravate the symptoms; the
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type, dosage, effectiveness, and side effects of any medication taken to alleviate pain or other
symptoms; and treatment, other than medication, received for relief of pain or other symptoms.
20 C.F.R. § 404.1529(c); SSR 16-3p, 2016 WL 1119029, at *7. A claimant is “entitled to rely
exclusively on subjective evidence” to prove the severity and extent of their symptoms. Arakas,
983 F.3d at 96 (quoting Hines v. Barnhart, 453 F.3d 559, 563, 565 (4th Cir. 2006)). Thus, an
ALJ commits “reversible error by improperly increasing Plaintiff’s burden of proof by
‘effectively requiring’ [their] subjective symptoms to be ‘supported by objective evidence.’”
Christina W. v. O’Malley, Civil Action No. CDA-23-1325, 2024 WL 3819343, at *4 (D. Md.
Aug. 14, 2024) (quoting Arakas, 983 F.3d at 96); see also Stoker v. Saul, 833 Fed. Appx. 383,
386 (4th Cir. 2020) (finding that “the ALJ’s determination that [the claimant’s] assertions about
the severity and limiting effects of his pain were less credible merely because no objective
medical evidence supported them, was improper”).
Here, Plaintiff argues that the ALJ applied an improper standard by discounting her
subjective complaints solely because they were not supported by objective medical evidence.
ECF No. 13 at 18–19. Plaintiff further contends that the ALJ failed to adequately evaluate the
intensity and persistence of her symptoms when determining her residual functional capacity. Id.
at 19. The Commissioner responds that the ALJ’s analysis of Plaintiff’s subjective complaints
was legally sufficient, and he provided valid reasons for his conclusions. ECF No. 15 at 19.
At step one of the framework, the ALJ determined that Plaintiff’s “medically
determinable impairments could reasonably be expected to cause the alleged symptoms.” ECF
No. 9-3 at 45. At the second step, the ALJ concluded that Plaintiff’s “statements concerning the
intensity, persistence and limiting effects of these symptoms [were] not entirely consistent with
the medical evidence and other evidence in the record.” Id. The record details, and the ALJ
summarized, that Plaintiff alleges disability based on congestive heart failure, diabetes mellitus,
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hypertension, and a rotator cuff tear and carpal tunnel syndrome. Id. at 44. Plaintiff testified that
she experiences daily angina, chest spasms related to her sternal wound, shortness of breath with
minimal exertion, and numbness and tingling in her hands, particularly on her right side. Id. at
44–45; ECF No. 9-6 at 102, 107. In assessing Plaintiff’s symptoms related to these complaints,
the ALJ cited Plaintiff’s hearing testimony and medical records. ECF No. 9-3 at 45–48. The
ALJ’s evaluation of Plaintiff’s subjective statements is inadequate. The ALJ failed to explain
why certain evidence was credited over Plaintiff’s testimony and improperly evaluated evidence
regarding Plaintiff’s daily activities.
In Willis F. v. Kijakazi, this Court found that the ALJ’s opinion did not provide a bridge
between the evidence and the ALJ’s conclusion because the ALJ did not explain how the
objective medical evidence “either undermine[d] or [was] entitled to more weight than Plaintiff’s
continued reports of pain.” Civil Action No. AAQ-23-318, 2023 WL 8437229, at *2-3 (D. Md.
Dec. 5, 2023); accord Candace W. v. Dudek, Civil Action No. ADC-24-2124, 2025 WL 885998,
at *4 (D. Md. Mar. 21, 2025); Kevin T. v. O’Malley, Civil Action No. CDA-23-312, 2023 WL
8993664, at *4 (D. Md. Dec. 28, 2023); Towanna G. v. Kijakazi, Civil Action No. BAH-21-
1711, 2022 WL 4017417, at *4 (D. Md. Sept. 2, 2022).
Similarly, here, the ALJ did not “build an accurate and logical bridge” between the
evidence and his conclusion. Stoker, 833 Fed. Appx. at 386 (quoting Brown v. Commissioner
Soc. Sec. Admin., 873 F.3d 251, 269 (4th Cir. 2017)). The ALJ acknowledged that Plaintiff
reported daily chest pain and spasms requiring her to lie down for up to four hours, difficulty
walking or climbing stairs without becoming winded, and limited ability to reach overhead or
use her hands. ECF No. 9-3 at 44–45. He also noted that she testified that she no longer cooks,
cleans, shops, or manages her finances; relies on her daughter for household tasks and personal
care; and limits her activities to resting and maintaining comfort at home. Id. The ALJ then
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summarized the opinions of several medical examiners and concluded that “various factors
[were] inconsistent with limitations to the degree alleged.” Id. at 47. In support of that
conclusion, the ALJ citied Plaintiff’s conservative treatment, post-surgical stability, minimal
treatment for carpal tunnel syndrome and shoulder impairment, and improved diabetes control.
Id. The ALJ did not, however, explain how those findings undermined Plaintiff’s specific
allegations of pain, fatigue, and functional limitation. Furthermore, the ALJ provided no
explanation of why Plaintiff’s allegations of pain and limitations were entitled to less weight than
other evidence in the record. Willis F., 2023 WL 8437229, at *3; see also Towanna G., 2022
WL 4017417, at *4 (reversing and remanding where the ALJ “failed to effectively explain how
the objective medical evidence contradicts Plaintiff’s subjective complaints”) (emphasis in
original).
When assessing daily activities, an “ALJ may not consider the type of activities a
claimant can perform without also considering the extent to which [the claimant] can perform
them.” Oakes v. Kijakazi, 70 F.4th 207, 216 (4th Cir. 2023) (emphasis in original) (quoting
Woods v. Berryhill, 888 F.3d 686, 694) (4th Cir. 2018)). As the Fourth Circuit has explained,
“[d]isability claimants should not be penalized for attempting to lead normal lives in the face of
their limitations.” Lewis v. Berryhill, 858 F.3d 858, 868 n.3 (4th Cir. 2017) (internal quotation
marks and citations omitted). “Being able to live independently and participate in everyday
activities of life empowers people with disabilities and promotes their equal dignity.” Arakas,
983 F.3d at 101.
Here, the ALJ relied on Plaintiff’s statements to providers that she was “able to perform
her activities of daily living” but failed to reconcile those statements with Plaintiff’s testimony
that she no longer cooks, cleans, shops, or manages her own finances, and instead relies on
family members for assistance. ECF No. 9-3 at 47. As the Fourth Circuit held in Oakes, an ALJ
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may not rely on the mere ability to perform daily activities without considering their frequency,
duration, or the assistance required. 70 F. 4th at 216. The ALJ’s assertion that Plaintiff’s
impairments “impose some limitation,” but that the degree of limitation was “accounted for” in
the residual functional capacity analysis, does not cure this defect. ECF No. 9-3 at 47. That
conclusory statement does not explain how the evidence is inconsistent, which limitations were
discounted, or why some evidence was credited over other allegedly inconsistent evidence. For
these reasons, the ALJ’s analysis of Plaintiff’s subjective statements is not supported by
substantial evidence, precludes meaningful review, and requires reversal.
E. Residual Functional Capacity
Finally, Plaintiff contends that substantial evidence does not support the ALJ’s residual
functional capacity finding. ECF No. 13 at 8–13. The Commissioner argues the opposite. ECF
No. 15 at 10–17. “When an individual is not engaging in substantial gainful activity and a
determination [regarding eligibility for benefits] . . . cannot be made on the basis of medical
factors alone . . . the sequential evaluation process generally must continue with an identification
of the individual’s functional limitations . . . and an assessment of his or her remaining capacities
for work-related activities.” SSR 96-8p, at 61 Fed. Reg. 34,475. The latter part of this analysis
is expressed as a claimant’s residual functional capacity, which is the most the claimant can do in
a work setting on a regular and continuing basis despite any impairments or related symptoms.
Id.; 20 C.F.R. § 404.1545; see also I.B, supra.
A claimant’s residual functional capacity is determined using a two-step process. The
ALJ must first “identify the individual’s functional limitations . . . and assess his or her work-
related abilities on a function-by-function basis.” SSR 96-8p, at 61 Fed. Reg. 34,475. “The
function-by-function approach asks the ALJ to consider a claimant’s specific ‘exertional and
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nonexertional functions.’”6 Ladda v. Berryhill, 749 Fed. Appx. 166, 173 (4th Cir. 2018)
(quoting SSR 96-8p, at 61 Fed. Reg. 34,476). The ALJ then expresses a claimant’s residual
functional capacity “in terms of the exertional levels of work,” such as “sedentary, light,
medium, heavy, and very heavy.” SSR 96-8p, 61 Fed. Reg. at 34,475; see also 20 C.F.R.
§ 404.1567 (defining the physical exertion requirements of each exertional level of work).
While the SSA guidelines require a “function-by-function” analysis to determine a
claimant’s residual functional capacity, the Fourth Circuit has held that this analysis does not
need to be explicit. Mascio, 780 F.3d at 636 (rejecting “a per se rule requiring remand when the
ALJ does not perform an explicit function-by-function analysis”). Instead, the key consideration
is whether the ALJ identified the evidence relied upon in determining the claimant’s residual
functional capacity and built “an accurate and logical bridge from the evidence to that
conclusion.” Monroe, 826 F.3d at 189 (internal quotation marks and citation omitted). A proper
residual functional capacity analysis “has three components: (1) evidence, (2) logical
explanation, and (3) conclusion.” Thomas, 916 F.3d at 311. The second component of this
analysis, “the ALJ’s logical explanation, is just as important as the other two.” Id.; see also SSR
96-8p, 61 Fed. Reg. at 34,478 (“The [residual functional capacity] assessment must include a
narrative discussion describing how the evidence supports each conclusion, citing specific
medical facts . . . and nonmedical evidence.”). Remand may be appropriate “where an ALJ fails
to assess a claimant’s capacity to perform relevant functions, despite contradictory evidence in
the record,” Mascio, 780 F.3d at 636 (internal quotation marks and citation omitted), or where
6 “Exertional capacity . . . defines the individual’s remaining abilities to perform each of
seven strength demands: [s]itting, standing, walking, lifting, carrying, pushing, and pulling.”
Social Security Ruling 96-8p, Titles II and XVI: Assessing Residual Functional Capacity in
Initial Claims, 61 Fed. Reg. 34,474-01, 34,477 (July 2, 1996). “Nonexertional capacity
considers all work-related limitations and restrictions that do not depend on an individual’s
physical strength,” such as stooping, climbing, reaching, seeing, hearing, speaking,
understanding and remembering instructions, and tolerance of temperature extremes. Id.
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the ALJ’s residual functional capacity analysis “contains too little logical explanation for . . .
meaningful appellate review,” Thomas, 916 F.3d at 312.
Here, the ALJ determined in the residual functional capacity assessment that Plaintiff
could perform light work. ECF No. 9-3 at 44. Among other things, light work “requires a good
deal of walking or standing” or “sitting most of the time with some pushing and pulling of arm or
leg controls.”7 20 C.F.R. § 404.1567(b). To reach this conclusion, the ALJ assessed Plaintiff’s
symptoms, as well as objective medical evidence, medical opinions, and prior administrative
medical findings. ECF No. 9-3 at 44. As noted, see I.C., supra, the ALJ identified several
exceptions to Plaintiff’s capacity for light work. Id. Although the ALJ summarized evidence
from the record relevant to this conclusion, he did not explain how that evidence supported the
specific limitations imposed, or the ultimate conclusion that Plaintiff could perform light work.
The decision therefore lacks the required logical bridge between the evidence and the residual
functional capacity determination.
This deficiency is illustrated by the ALJ’s discussion of two prior administrative medical
findings. Id. at 47. The ALJ summarized an October 28, 2022 medical opinion that concluded
the plaintiff “could perform light exertion work, could occasionally climb ladders, ropes, or
scaffolds, stoop, and crawl, and could never reach overhead with the right arm.” ECF Nos. 9-3
at 47; 9-7 at 2–8. The ALJ then noted that “[u]pon reconsideration [on] May [9,] 2023, a state
7 “Light work involves lifting no more than 20 pounds at a time with frequent lifting or
carrying of objects weighing up to 10 pounds. Even though the weight lifted may be very little, a
job is in this category when it requires a good deal of walking or standing, or when it involves
sitting most of the time with some pushing and pulling of arm or leg controls. To be considered
capable of performing a full or wide range of light work, you must have the ability to do
substantially all of these activities. If someone can do light work, we determine that he or she
can also do sedentary work, unless there are additional limiting factors such as loss of fine
dexterity or inability to sit for long periods of time.” 28 C.F.R. § 404.1567(b); see also Titles II
& XVI: Determining Capability to Do Other Work—the Med.-Vocational Rules of Appendix 2,
SSR 83-10 (S.S.A. 1983), 1983 WL 31251, at *5-6.
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agency reviewing physician agreed that claimant could perform light exertion work but instead
determined that the claimant had no postural or manipulative limitations, but should avoid
concentrated exposure to extreme temperatures and pulmonary irritants.” ECF Nos. 9-3 at 47; 9-
7 at 10–15. (emphasis added). The ALJ found these medical opinions to be “somewhat
consistent with evidence from the record” without explaining how they are inconsistent or
specifically citing other inconsistent evidence. ECF No. 9-3 at 47. Thus, the ALJ “fail[ed] to
assess [the] claimant’s capacity to perform relevant functions, despite contradictory evidence in
the record.” Mascio, 780 F.3d at 636 (internal quotation marks and citation omitted). The ALJ
did not explain what aspects of the physician’s opinions were credited or rejected, how the
physician’s differing assessments of postural and manipulative limitations were resolved, or how
those opinions supported the specific limitations included in the residual functional capacity
assessment. Nor did the ALJ explain how these opinions, taken together, supported the
conclusion that Plaintiff could meet the standing or walking demands of light work.
The ALJ’s conclusions regarding the limitations on Plaintiff’s ability to handle, finger,
feel, push, pull, or reach suffer from the same defects. The record contains varying opinions on
Plaintiff’s capacity to perform those functions. Compare ECF No. 9-7 at 2–8 with 9-7 at 10–15.
Yet, the ALJ merely stated that Plaintiff’s impairments imposed “some limitations” and that the
residual functional capacity accounted for the degree of limitation supported by the record. ECF
No. 9-3 at 47. This conclusory statement does not explain how the ALJ weighed the conflicting
evidence or why the chosen limitations were appropriate. Elijah H. v. O’Malley, Civil Action
No. SAG-23-1786, 2024 WL 1833608, at *4 (D. Md. Apr. 26, 2024) (finding a lack of
explanation constitutes reversible error); Christina W., 2024 WL 3819343, at *5 (same).
Because the ALJ’s discussion does not describe how the evidence supports the residual
functional capacity finding, it “contains too little logical explanation for . . . meaningful appellate
review.” Thomas, 916 F.3d at 312.
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III. CONCLUSION
For the foregoing reasons, the Commissioner’s decision is reversed, and the case is
remanded for further proceedings consistent with this Memorandum Opinion pursuant to
sentence four of 42 U.S.C. § 405(g). In remanding for further explanation and analysis, the
Court offers no opinion as to whether the ALJ’s ultimate conclusion that Plaintiff is not entitled
to benefits is correct. A separate Order follows.
Date: February 6, 2026 /s/
Erin Aslan
United States Magistrate Judge
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