Case Name in Social Security Case - Unavailable

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IN THE UNITED STATES DISTRICT COURT
FOR THE MIDDLE DISTRICT OF PENNSYLVANIA
MICHELLE NELLIS, 	: 	Civil No. 4:24-CV-1849
:
Plaintiff, 	:
:
v. 	: 	(Magistrate Judge Carlson)
:
FRANK BISIGNANO,1 :
Commissioner of Social Security 	:
:
Defendant. 	:
MEMORANDUM OPINION
I. 	Introduction
In many instances, the ability to reach is an essential attribute in the modern
workplace. Therefore, individuals whose ability to reach has been significantly
eroded by physical impairments often are unable to perform sustained work. For
such disabled individuals Social Security provides a crucial financial safety net.
However, before claimants are entitled to disability benefits under the Social
Security Act due to issues pertaining to their ability to reach, it must be shown that
they meet the stringent requirements prescribed by law and Administrative Law
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).
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Judges, (ALJs), are charged with the responsibility to carefully assess such claims.
Further, it is the responsibility of the ALJ to clearly and thoroughly articulate the
basis for the denial of a disability claim based upon reach impairments. Once the
ALJ completes this task, on appeal it is the duty of the district court to review these
ALJ findings, judging the findings against a deferential standard of review which
simply asks whether the ALJ’s decision is 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), a quantum
of proof which “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).
Yet while this is a deferential substantive standard of review, it is also
incumbent upon the ALJ to sufficiently articulate the rationale for the decision to
allow for meaningful judicial review. Where this duty of articulation is not fully
satisfied, a remand is appropriate.
So it is here.
In the instant case, the ALJ denied a disability application submitted by the
plaintiff, Michelle Nellis. Nellis alleged she was disabled by a cascading array of
severe physical and emotional impairments including May-Thurner syndrome, deep
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vein thrombosis (DVT), diabetes, and depression. The record also showed that, in
2023, she was diagnosed with adhesive capsulitis, resulting in pain and decreased
range of motion in her right shoulder. The fact of Nellis’ decreased range of motion
in her right shoulder was described by Nellis at the hearing on her disability claim
and consultative examination results showing decreased range of motion in all
spheres of reaching also reinforced this limitation. Moreover, the consultative
examiner opined that she would be limited to occasionally reaching in any direction
and never reaching overhead.
Nonetheless, in denying Nellis’ disability claim, the ALJ found that she could
perform light work and was limited to only occasional overhead reaching with her
right arm but, without explanation, provided no limitations in reaching in any other
direction with her right arm. (Tr. 15). This conclusion was curious since the ALJ
acknowledged evidence that Nellis had decreased range of motion in all directions,
yet the ALJ did not explain why the examination results would only limit her ability
to reach overhead. This unexplained limitation was problematic because a vocational
expert testified that any limitations in overhead reaching, including never reaching
overhead, would not affect Nellis’ ability to perform the jobs he identified but that a
limitation to occasional reaching in all other directions would be work preclusive at
the light exertional level.
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Considering the outcome determinative nature of this narrow issue, after a
review of the record, we find that the ALJ failed to adequately explain this aspect of
the RFC finding, and thus the ALJ’s RFC determination is not supported by
substantial evidence. Accordingly, we recommend that the Court remand this case
for further consideration by the Commissioner.
II. 	Statement of Facts and of the Case
On October 6, 2022, Michelle Nellis filed a Title II application for a period of
disability and disability insurance benefits, alleging disability beginning January 1,
2017. (Tr. 10). In her application, Nellis cited a cascading array of severe physical
impairments as disabling, including blind or low vision, diabetes, prothrombin
mutations, May-Thurner syndrome, DVT left leg from foot to kidney, pre-infarction
syndrome, chronic DVT, and depression. (Tr. 61). 	Nellis was born on October 2,
1972, and was forty-four years old, which is defined as a younger individual, on the
alleged disability onset date. (Id.). She later changed age categories and was
considered an individual closely approaching advanced age at the time of her
hearing. (Id.) She had prior employment as a retail manager. (Tr. 54).
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With respect to her physical impairments, the clinical record, medical
opinions, and Nellis’ testimony confirmed that her ability to reach was compromised
by her adhesive capsulitis.2
The longitudinal record of her shoulder impairment shows that in May 2023
she presented to the emergency department complaining of right shoulder pain
worsening since January 2023. (Tr. 715). She described being in “terrible pain”
especially with quick movements. (Id.) The physician explained she had limited
range of motion and significant pain and weakness, and an examination showed
painful range of motion overhead and above 90 degrees in all planes and that she
was unable to reach behind her back because of pain on both the superior and anterior
aspect of the shoulder. (Tr. 716). She was prescribed Tylenol #3 and referred to
orthopedics and physical therapy (Id.) In May 2023 she was diagnosed with adhesive
capsulitis by an orthopedic clinic. (Tr. 768). Physical therapy was recommended and
a fluoroscopy guided intra-articular corticosteroid injection was scheduled for June
2023. (Id.) It was noted that her impairment significantly impacted her range of
motion. (Id.) She underwent an intra-articular corticosteroid injection in June 2023
which provided her immediate pain relief, (tr. 784), but by April 2024, she returned
2 Because we have determined that the treatment of Nellis’ physical limitations, by
itself, warrants a remand of this case, we have limited our review of the evidence to
these physical impairments which affected her ability to reach overhead.
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to orthopedics reporting her shoulder symptoms had recurred the prior month. (Tr.
855). She reported pain lifting her arm away from her body or overhead and at night
while at rest. (Id.) An examination again showed limited range of motion in all
planes with positive Hawkins and Neer’s. (Id.) She was diagnosed with recurrent
adhesive capsulitis, rotator cuff tendinopathy, (id.), and underwent a second intra-
articular corticosteroid injection in May 2024. (Tr. 862).
During this period, Nellis also underwent a consultative examination with Dr.
Ahmed Kneifati on January 24, 2024. (Tr. 829-33). Dr. Kneifati noted limited
motion of the right shoulder due to rotator cuff tear and adhesive capsulitis with
stiffness and pain. (Tr. 830, 832). His examination notes revealed Nellis’ range of
motion of her right shoulder was limited in all planes including forward elevation,
abduction, adduction, internal rotation, and external rotation. (Tr. 840).
Thus, the clinical record consistently reinforced that Nellis had significant
pain, stiffness, and limited range of motion in her right shoulder limiting her ability
to reach in all directions. This record was reinforced by Nellis’ own testimony at the
hearing, when she stated she cannot reach overhead at all with her right shoulder,
that her shoulder gets “stuck” if she moves it in the wrong direction, and that she has
difficulties reaching straight ahead or above chest level. (Tr. 46).
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This clinical evidence, and Nellis’ account of her impairments, led both
medical sources who opined on her physical abilities to conclude that her ability to
reach was compromised. However, these experts reached different conclusions on
the extent of this limitation. On this score, on January 24, 2024, the physician who
examined Nellis, Dr. Kneifati, opined that Nellis could never reach overhead and
could only occasionally reach in all other directions with her right hand. (Tr. 836).
This opinion was consistent with Dr. Kneifati’s examination findings and the clinical
findings in the record that Nellis had reduced range of motion in her right arm in all
planes and with Nellis’ testimony that she could never reach overhead.
On February 27, 2024, a non-examining State agency medical consultant Dr.
Josie Mae Henderson also concluded Nellis would be limited in reaching with her
right hand and concluded she would only be limited to occasionally reaching
overhead with her right upper extremity due to shoulder pain and decreased range of
motion but would be unlimited in her ability to reach in front and/or laterally. (Tr.
75). Yet this non-examining source opinion could not be readily reconciled with the
clinical evidence when it came to consideration of Nellis’ inability to reach with her
right extremity and was unexplained with regard to the limitations in reaching.
Indeed, while Dr. Henderson acknowledged right shoulder pain and decreased range
of motion in the record, she failed to explain why the reduced range of motion would
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only require limitations in Nellis’ ability to reach overhead when examinations
clearly showed limitations in all planes. Moreover, Dr. Henderson conceded that the
opinion of Dr. Kneifati was “partially supportable and partially consistent” with the
clinical evidence yet failed to reconcile Dr. Kneifati’s additional limitations in
reaching with her much less comprehensive opinion. (Tr. 75-77).
It is against the backdrop of this evidence that the ALJ conducted a hearing in
Nellis’ case on June 26, 2024. (Tr. 35-59). Nellis and a vocational expert (VE) both
testified at this hearing. (Id.) At the hearing, the vocational expert testified that an
individual with Nellis’ RFC who could never overheard reach with the right hand
could still perform the jobs he identified. However, the VE testified that if a person
could only reach occasionally with their dominant right hand in all other planes, that
individual would be unable to perform any jobs at the light exertional level. (Id.)
Thus, the issue of whether Nellis could reach overhead would not have changed her
ability to perform work at the light exertional level, but the question of whether
Nellis could reach in all other planes was outcome determinative.
Following this hearing, on June 28, 2024, the ALJ issued a decision denying
Nellis’ application for benefits. (Tr. 7-25). In that decision, the ALJ first concluded
Nellis met the insured requirements of the Act through September 30, 2027, and had
not engaged in substantial gainful activity since September 7, 2021, the alleged onset
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date of her disability. (Tr. 12-13). At Step 2 of the sequential analysis that governs
Social 	Security 	cases, 	the 	ALJ 	found 	that 	Nellis 	had 	the 	following 	severe
impairments: adhesive capsulitis, May-Thurner syndrome, deep vein thrombosis,
and diabetic peripheral neuropathy. (Tr. 13). At Step 3 the ALJ determined that none
of these impairments met or medically equaled the severity of any of the listed
impairments. (Tr. 14-15).
Between Steps 3 and 4 the ALJ concluded that Nellis retained the following
residual functional capacity (“RFC”):
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) except the claimant can
stand/walk for only 4 hours during an 8-hour workday; can only
occasionally perform postural movements; can occasionally reach
overhead with her right upper extremity; and must avoid concentrated
exposure 	to 	loud 	noise, 	vibrations, 	dangerous 	machinery, 	and
unprotected heights.
(Tr. 15).
Notably, this 	RFC provided 	that 	Nellis could 	only 	occasionally 	reach
overhead with her right upper extremity, but made no provision for Nellis’ limited
range of motion in other planes, a physical limitation that was fully supported by the
clinical evidence, the statements of Nellis, and Dr. Kneifati. Curiously, in reaching
this conclusion, the ALJ acknowledged the evidence clinical evidence which showed
Nellis had limited range of motion in her shoulder in all directions, explaining:
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In May 2023, the claimant presented to the emergency department with
complaints of right shoulder pain, present since January 2023 (Exhibit
B12F, page 92). On physical examination, her right shoulder was
shown to have painful range of motion above 90 degrees in all planes
and her strength was decreased when compared to her left upper
extremity (Exhibit B12F, page 93). The claimant was referred to
orthopedics (Exhibit B12F, page 93) and physical therapy (Exhibit
B13F). The claimant was diagnosed with adhesive capsulitis of her
right shoulder (Exhibit B16F, page 12) and was administered an intra-
articular corticosteroid injection in June 2023 (Exhibit B16F, page 10).
In April 2024, the claimant returned to orthopedics reporting that while
her injection provided significant relief of her symptoms initially, her
symptoms of shoulder pain recurred the prior month (Exhibit B18F,
page 10). On 	physical 	examination, the claimant 	presented 	with
diminished strength, limited range of motion, and positive Hawkins and
Neer’s testing (Exhibit B18F, page 10). The claimant was provided
another injection in May 2024 (Exhibit B18F, page 18) (Tr. 17)
(Tr. 17). Thus, the ALJ acknowledged that Nellis’ adhesive capsulitis was a severe
condition that limited her range of motion in all planes, yet failed to explain why this
record supported only limitations to occasional reaching overhead but no limitation
reaching any other direction. The ALJ also acknowledged the examination findings
of Dr. Kneifati, but concluded that:
However, the claimant showed no evidence of lower extremity edema,
impaired upper or lower extremity strength, diminished hand or finger
dexterity, or sensory deficit. . . . These observations suggest the
claimant retains a greater capacity for sustained functional activities
than opined in her disability application and appeal and further support
the above assessment of the claimant’s residual functional capacity.
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(Id.) In support of the RFC, the ALJ seemingly explained that no further limitations
were 	necessary 	due 	to 	intact 	strength 	and 	sensation 	in 	Nellis’ 	extremities,
examination findings which have no bearing on her ability to reach in all directions.
The ALJ then found the opinion of Dr. Henderson persuasive, stating that her
opinion that Nellis should be limited to no more than occasional overhead reaching
was well-supported by physical examination records throughout the file showing
Nellis “retains a good capacity for sustained strength and ambulation . . . despite
limited right shoulder range of motion.” (Tr. 17-18). The ALJ did not explain why
the examination records showing limited range of motion only affected Nellis’
ability to reach overhead. The ALJ then found the opinion of consultative examiner
Dr. Kneifati unpersuasive, but in finding Dr. Kneifati’s opinion inconsistent with his
observations and poorly supported by medical treatment records, the ALJ addressed
only Nellis’ abilities with regard to her lower extremities and did not directly address
Dr. Kneifati’s opinion that she could only occasionally reach in all directions.
The ALJ then found at Step 4 that Nellis could not perform her past work as
a retail store manager but concluded at Step 5 that jobs existed in significant numbers
in the national economy that she could perform despite her impairments. (Tr. 19).
Notably, these were the jobs the VE testified at the hearing she would not be able to
perform if she were limited to only occasional reaching in all directions. (Tr. 56).
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Having reached these conclusions, the ALJ determined that Nellis had not met the
demanding showing necessary to sustain her claim for benefits and denied her claim.
(Tr. 19-20).
This appeal followed. (Doc. 1). On appeal, Nellis challenges the adequacy of
the ALJ’s RFC determination on multiple scores and specifically asserts that the ALJ
erred in assessing her right shoulder limitations. This case is fully briefed and is,
therefore, ripe for resolution. As discussed in greater detail below, we find that the
ALJ’s failure to adequately explain the decision to limit Nellis to occasional
overhead reaching but no provide no limitations in reaching all other directions
warrants a remand of this case given the evidence which revealed that her right
shoulder range of motion was severely limited in all planes. Accordingly, we
recommend 	that 	this 	decision 	be remanded 	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
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
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(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:
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-
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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 Swanger 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 matters is plenary); Ficca, 901 F.Supp.2d at 536 (“[T]he court has plenary
review of all legal issues . . . .”).
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Several fundamental legal propositions 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).
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
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decision careful scrutiny to ensure that the rationale for the ALJ’s actions is
sufficiently articulated to permit meaningful judicial review.
B. 	Initial Burdens of Proof, Persuasion, and Articulation for the ALJ
To receive benefits under the Social Security Act by reason of disability, a
claimant must demonstrate an inability to “engage in any substantial gainful activity
by reason of any medically determinable physical or mental impairment which can
be expected to result in death or which has lasted or can be expected to last for a
continuous period of not less than 12 months.” 42 U.S.C. §423(d)(1)(A); 42 U.S.C.
§1382c(a)(3)(A); see also 20 C.F.R. §§404.1505(a), 416.905(a). To satisfy this
requirement, a claimant must have a severe physical or mental impairment that
makes it impossible to do his or her previous work or any other substantial gainful
activity that exists in the national economy. 42 U.S.C. §423(d)(2)(A); 42 U.S.C.
§1382c(a)(3)(B); 20 C.F.R. §§404.1505(a), 416.905(a). To receive benefits under
Title II of the Social Security Act, a claimant must show that he or she contributed
to the insurance program, is under retirement age, and became disabled prior to the
date on which he or she was last insured. 42 U.S.C. §423(a); 20 C.F.R. §404.131(a).
In making this determination at the administrative level, the ALJ follows a
five-step sequential evaluation process. 20 C.F.R. §§404.1520(a), 416.920(a).
Under this process, the ALJ must sequentially determine: (1) whether the claimant
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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 RFC. 20 C.F.R. §§404.1520(a)(4), 416.920(a)(4).
Between Steps 3 and 4, the ALJ must also assess a claimant’s RFC. The RFC
is defined as “that which an individual is still able to do despite the limitations caused
by his or her impairment(s).” Burnett, 220 F.3d at 121 (citations omitted); see also
20 C.F.R. §§404.1520(e), 404.1545(a)(1), 416.920(e), 416.945(a)(1). In making this
assessment, 	the 	ALJ 	considers 	all 	of 	the 	claimant’s 	medically 	determinable
impairments, including any non-severe impairments identified by the ALJ at step
two of his or her analysis. 20 C.F.R. §§404.1545(a)(2), 416.945(a)(2).
Once the ALJ has made this determination, our review of the ALJ’s
assessment of the plaintiff’s RFC is deferential, and that RFC assessment will not be
set aside if it is supported by substantial evidence. Burns v. Barnhart, 312 F.3d 113,
129 (3d Cir. 2002); see also 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); Metzger v. Berryhill,
No. 3:16-CV-1929, 2017 WL 1483328, at *5 (M.D. Pa. Mar. 29, 2017), report and
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recommendation adopted sub nom. Metzgar v. Colvin, No. 3:16-CV-1929, 2017 WL
1479426 (M.D. Pa. Apr. 21, 2017)..
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), 416.912(f); Mason, 994 F.2d at 1064.
There is an undeniable medical aspect to an RFC determination, since that
determination entails an assessment of what work the claimant can do given the
physical limitations that the claimant experiences. Yet, when considering the role
and necessity of medical opinion evidence in making this determination, courts have
followed several different paths. Some courts emphasize the importance of medical
opinion support for an RFC determination and state that “[r]arely can a decision be
made regarding a claimant’s [RFC] 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,
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it has been held that “[t]here is no legal requirement that a physician have made the
particular findings that an ALJ adopts in the course of determining an RFC.”
Titterington v. Barnhart, 174 F. App’x 6, 11 (3d Cir. 2006). Further, courts have held
in cases where there is no evidence of any credible medical opinion supporting a
claimant’s allegations of disability that “the proposition that an ALJ must always
base his RFC on a medical opinion from a physician is misguided.” Cummings v.
Colvin, 129 F.Supp.3d 209, 214–15 (W.D. Pa. 2015).
These 	seemingly 	discordant 	legal 	propositions 	can 	be 	reconciled 	by
evaluation of the factual context of these decisions. Those cases which emphasize
the importance of medical opinion support for an RFC assessment typically arise in
the factual setting, like that presented here, where well-supported medical sources
have opined regarding limitations which would support a disability claim, but an
ALJ has rejected the medical opinion which supported a disability determination
based upon a lay assessment of other evidence. Biller, 962 F.Supp.2d at 778–79. In
this setting, these cases simply restate the commonplace idea that medical opinions
are entitled to careful consideration when making a disability determination,
particularly when those opinions support a finding of disability. In contrast, when
no medical opinion supports a disability finding or when an ALJ is relying upon
other evidence, such as contrasting clinical or opinion evidence or testimony
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regarding the claimant’s activities of daily living, to fashion an RFC courts have
adopted 	a 	more 	pragmatic 	view 	and 	have 	sustained 	the 	ALJ’s 	exercise 	of
independent judgment based upon all of the facts and evidence. See Titterington,
174 F. App’x 6; Cummings, 129 F.Supp.3d at 214–15. In either event, once the ALJ
has made this determination, our review of the ALJ’s assessment of the plaintiff’s
RFC is deferential, and that RFC assessment will not be set aside if it is supported
by substantial evidence. Burns, 312 F.3d 113; see also Rathbun, 2018 WL 1514383,
at *6; Metzger, 2017 WL 1483328, at *5.
The ALJ’s disability determination must also meet certain basic substantive
requisites. Most significant among these legal benchmarks is a requirement that the
ALJ adequately explain the legal and factual basis for this disability determination.
Thus, in order to facilitate review of the decision under the substantial evidence
standard, the ALJ’s decision must be accompanied by “a clear and satisfactory
explication of the basis on which it rests.” Cotter v. Harris, 642 F.2d 700, 704 (3d
Cir. 1981). Conflicts in the evidence must be resolved and the ALJ must indicate
which evidence was accepted, which evidence was rejected, and the reasons for
rejecting certain evidence. Id. at 706-707. In addition, “[t]he ALJ must indicate in
his decision which evidence he has rejected and which he is relying on as the basis
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for his finding.” Schaudeck v. Comm’r of Soc. Sec., 181 F. 3d 429, 433 (3d Cir.
1999).
This principle applies with particular force to a claimant’s limitations in terms
of reaching and reaching overhead. Therefore, when an ALJ fashions an RFC which
does not fully account for and address reaching restrictions, a remand is often
necessary. See Swanger v. O'Malley, No. 3:23-CV-1730, 2024 WL 4343550, at *1
(M.D. Pa. Sept. 5, 2024), report and recommendation adopted, No. 3:23-CV-01730,
2024 WL 4339996 (M.D. Pa. Sept. 27, 2024); Stockett v. Comm’r of Soc. Sec., 216
F. Supp. 3d 440, 461 (D.N.J. 2016); Gamret v. Colvin, 994 F. Supp. 2d 695, 699
(W.D. Pa. 2014).
C. 	This Case Should be Remanded for Further Consideration by the
Commissioner.
As we have noted, an ALJ’s decision must be accompanied by “a clear and
satisfactory explication of the basis on which it rests.” Cotter, 642 F.2d at 704.
Furthermore, the ALJ must also “indicate in his decision which evidence he has
rejected and which he is relying on as the basis for his finding.” Schaudeck, 181 F.3d
at 433. This cardinal principle applies with particular force to several types of
assessment made by ALJs. With respect to the instant case, it is well settled that
“[t]he ALJ must consider all relevant evidence when determining an individual’s
residual functional capacity.” Fargnoli v. Massanari, 247 F.3d 34, 41 (3d Cir. 2001).
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Therefore, an ALJ must “explain his reasons for discounting all of the pertinent
evidence before him in making his residual functional capacity determination.”
Burnett v. Comm’r of Soc. Sec. Admin., 220 F.3d 112, 121 (3d Cir. 2000).
In the instant case, we conclude that the ALJ’s RFC determination is not
supported by an adequate explanation with respect to Nellis’ reaching restrictions.
As we have noted, the clinical evidence reveals that Nellis’ examinations starting in
early 2023, when she was first diagnosed with adhesive capsulitis, repeatedly noted
that this condition significantly limited the range of motion in her right shoulder in
all planes. (Tr. 716, 768, 855, 862). This clinical evidence was reinforced by the
examination of Dr. Kneifati, which showed Nellis’ right shoulder range of motion
was limited in all planes including forward elevation, abduction, adduction, internal
rotation, and external rotation. (Tr. 840). Nellis herself also testified that she could
not overhead reach at all with her right shoulder and had difficulties reaching straight
ahead or above chest level. (Tr. 46).
Further, Dr. Kneifati, who examined the plaintiff, opined that her ability to
reach was significantly compromised in that she could never reach overheard with
her right arm and could only occasionally reach in all other directions. It was only
the unexplained opinion of the non-treating source, Dr. Henderson, which supported
the RFC crafted by the ALJ. Yet, Dr. Henderson’s opinion similarly credited the
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record showing Nellis suffered limited range of motion in all planes in her right arm,
yet inexplicably concluded she could only occasionally reach overhead but had no
limitations in reaching in any other direction.
Against this body of evidence which unequivocally shows Nellis was limited
in her ability to reach not just overhead but in all directions, the ALJ fashioned an
RFC that mirrored that of the non-examining source who had concluded only that
Nellis should be limited to occasional overhead reaching but made no other
accommodations for her limited range of motion. This went entirely unexplained in
the ALJ’s decision, which seemed to credit the records showing Nellis’ adhesive
capsulitis was a severe condition that limited her range of motion in all planes, yet
failed to explain why this record supported only limitations to occasional reaching
overhead but no limitation reaching any other direction and citing to intact strength
and sensation in Nellis’ extremities, examination findings which have no bearing on
her ability to reach in all directions.3
3 The Commissioner argues that the DOT does not distinguish between reaching
overheard and reaching in all other directions, thus the ALJ was justified in relying
on the VE testimony that she could perform the identified jobs even if limited to
overhead reaching. See Tammero v. Saul, No. 3:19-CV-02234, 2020 WL 7480661,
at *9 (M.D. Pa. Dec. 18, 2020) (explaining that the DOT is silent on overhead
reaching and an ALJ may rely on a VE’s expertise concerning specific limitations
to which h the DOT is silent). In our view, this argument only furthers our conclusion
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Further, the ALJ’s rejection of Dr. Kneifati’s opinion that she could never
reach overhead and could only occasionally reach in all other directions made no
mention of these limitations and why they were unpersuasive, focusing only on Dr.
Kneifati’s opinion on her abilities with regard to her lower extremities. Instead, the
ALJ 	seemingly 	adopted 	the upper extremity 	limitations 	opined 	by 	the non-
examining source, Dr. Henderson, who also failed to explain how the clinical record
supported limitations in some planes of reaching but not others.
On these facts, the failure to address or analyze all aspects of Nellis’ right arm
reach limitations was error. Moreover, given the testimony of the vocational expert
that limitations to occasional reaching in all directions would preclude Nellis from
working any occupation at the light exertional level, this unexplained failure by the
ALJ to include any limitations in reaching in all directions, despite the evidence
showing Nellis had significant limitations in her range of motion in all planes, was
a prejudicial error. Indeed, in this context where an ALJ’s incorporation of these
that more explanation was necessary on the part of the ALJ since, while the DOT
does not distinguish between the ability to reach overhead and reach in all other
directions, the ALJ clearly and intentionally did so here without explanation. This
was significant and required explanation where the VE testimony upon which the
ALJ was empowered to rely clearly showed that, had the ALJ limited Nellis to
occasional reaching in all directions she would not have been able to perform these
jobs.
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limitations would have resulted in a decision finding the plaintiff disabled, it was
incumbent upon the ALJ to provide an adequate explanation as to why the record
supported limitations in one area of reaching but not others.4
Given this constellation of factors, the ALJ’s failure to explain why further
limitations on Nellis’ ability to reach were not incorporated into this RFC was in
error. In our view, more is needed here given this disparity between the RFC and the
evidence. Thus, we conclude that the ALJ’s decision in this case is not supported by
substantial evidence, as the ALJ did not offer an adequate explanation for concluding
Nellis was limited in reaching in some directions but not others. Accordingly, we
will remand this case to the Commissioner for further consideration of this evidence.
Yet, while we find 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 should be. Instead, that
judgment should remain to province of the ALJ. Finally, because we have vacated
and remanded the decision of the Commissioner on these grounds, we decline to
address any other issues presented by the parties since “[a] remand may produce
4 We are also without explanation as to why, despite the examination findings and
Nellis’ own testimony that she could never reach over her head, the ALJ concluded
she could 	reach 	overhead 	occasionally. However, this 	issue is 	not 	outcome
determinative since the VE testified that she could still perform the jobs identified
even if she was limited to no overhead reaching.
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different results on these claims, making discussion of them moot.” Burns v. Colvin,
156 F.Supp.3d 579, 598 (M.D. Pa. Jan. 13, 2016).
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: March 19, 2026
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