Case Name in Social Security Case - Unavailable

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IN THE UNITED STATES DISTRICT COURT
FOR THE MIDDLE DISTRICT OF PENNSYLVANIA
FRED MCCLEARY, 	: 	Civil No. 4:25-CV-26
:
Plaintiff 	:
:
v. 	: 	(Magistrate Judge Carlson)
:
FRANK BISIGNANO,1 :
Commissioner of Social Security, 	:
:
Defendant. 	:
MEMORANDUM OPINION
I. 	Introduction
Social Security appeals lie at the intersection of law and medicine. While the
disability determination is ultimately a question of law, that legal issue is often
necessarily shaped by medical opinions. Informed decision-making in this field
therefore requires that legal and medical decisionmakers share a common and
commonly understood lexicon.
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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What then happens when judges, lawyers and medical personnel ascribe
different meanings to terms which may determine the outcome of disability
decisions? Oftentimes the result is confusion which defeats reasoned analysis.
So it is here.
The plaintiff, Fred McCleary applied for disability citing a cascading array of
severe mental impairments, conditions which McCleary stated left him with a
paralyzing inability to follow the simplest of instructions. McCleary’s treating
caregiver 	agreed, 	stating 	that 	he 	was 	totally 	disabled 	by 	these 	emotional
impairments.
However, the Administrative Law Judge (ALJ) who decided this case
disagreed with this assessment and denied McCleary’s claim. In doing so, the ALJ
endeavored to navigate an array of ambiguous and internally inconsistent medical
opinions from non-treating sources. First, the ALJ considered two opinions by state
agency experts which used a legal term of art in a casual and casually incoherent
way. These state agency experts indicated that McCleary’s mental impairments only
mildly impaired his ability to follow simple instructions but then paradoxically
stated that McCleary could understand one-to-two-step tasks. These were curious
opinions because the experts’ references to one-to-two-step tasks involved a term of
art in Social Security practice which connotes jobs limited to reasoning level 1 since
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the definition of this reasoning level is confined to jobs which entail: “Apply[ing]
commonsense understanding to carry out simple one- or two-step instructions.”
Dictionary of Occupational Titles, Appendix C - Components of the Definition
Trailer, 1991 WL 688702. Thus, the state agency experts’ opinions that McCleary
could perform one- and two-step tasks were tantamount to a finding that he was
limited to reasoning level 1 jobs, and was inconsistent with the experts’ conclusions
that McCleary was only mildly impaired in terms of following simple instructions.
This initial confusion stemming from the medical experts’ casual use of a term
which has legal significance was then compounded by the ALJ who suggested that
these medical opinions were not fully persuasive because they did not adequately
consider the severity of McCleary’s limitations in following simple instructions.
After finding that this aspect of the state agency experts’ opinions was unpersuasive
because they understated the degree of his impairment, the ALJ declared that the
opinion of a consulting examining source had greater persuasive power. But this
consultant’s opinion found that McCleary had no difficulty following simple
instructions, a finding which, under the ALJ’s stated rationale, should have rendered
the consultant opinion even less persuasive than the state agency experts.
The ALJ then declared that McCleary was moderately impaired in terms of
understanding and applying information, a conclusion which was inconsistent with
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all of the medical opinions the ALJ found persuasive. Finally, the ALJ arrived at a
mental residual functional capacity assessment for McCleary which was seemingly
unmoored to any medical opinion and concluded that he had the mental capacity to
maintain concentration, persistence, or pace for two-hour segments sufficient to
perform routine two-to-three-step tasks or instructions.
McCleary now appeals this decision challenging the ALJ’s mental RFC
analysis. In our view, the ALJ’s internally inconsistent analysis rests upon three legal
infirm foundations: First, it fails to recognize a casual conflation of concepts by state
agency experts. Second, it rejects evidence for no reason or for the wrong reason.
Finally, this medical opinion analysis does not provide the essential logical nexus
between 	medicine 	and 	law 	that 	is 	necessary 	for 	informed 	decision-making.
Therefore, we will order this case remanded for further consideration by the
Commissioner.
II. 	Statement of Facts and of the Case
A. Introduction
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On April 18, 2022, Fred McCleary applied for disability and disability
insurance benefits along supplemental security income pursuant to Titles II and XVI
of the Social Security Act, alleging an onset of disability beginning February 24,
2021. (Tr. 10). In these applications McCleary alleged that he was disabled due to
an array of physical and mental impairments, including degenerative disc disease of
the 	lumbar 	spine 	and 	cervical 	spine, 	osteoarthritis 	of 	the 	knees, 	mild
tricompartmental marginal spurring of the right ankle, obesity, depression, anxiety,
post-traumatic stress disorder, bipolar disorder, substance use disorder (marijuana
use), 	obsessive 	compulsive 	disorder, 	attention 	deficit 	hyperactivity 	disorder,
intermittent explosive disorder, and personality disorder. (Tr. 13).
McCleary on was born on February 26, 1975 and was forty-five years old at
the time of the alleged onset of his disability, making him a younger worker under
the Commissioner’s regulations. (Tr. 27). His formal education ended in the eighth
grade, although he later obtained a GED online reportedly with extensive assistance
from his paramour. (Tr. 54). He had prior employment as a fast food cook. (Tr. 27).
B. McCleary’s Mental Impairments and the Expert Opinions Regarding
Those Limitations.
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For his part, McCleary has consistently described the severity of his emotional
impairments in terms which were disabling. As the ALJ observed:
As to the claimant’s mental impairments, the claimant has alleged
experiencing symptoms of difficulty falling asleep, crying spells,
hopelessness, a loss of usual interests, irritability, fatigue, a loss of
energy, diminished self-esteem, difficulty concentrating, a diminished
sense of pleasure, social withdrawal, excessive apprehension and
worry, being easily fatigued, a fear of being judged or negatively
evaluated in social settings, avoidance of social 	settings, phobic
responses around crowds and in close space, a hyper startle response,
nightmares, 	hypervigilance, 	avoidance, 	intrusive 	thoughts, 	anger
outbursts, detachment from others, panic attacks, auditory and visual
hallucinations, 	paranoia, 	racing 	thoughts, 	restlessness, 	repetitive
behaviors, anhedonia, suicidal ideation, guilt, worthlessness, and short-
term memory deficits. The claimant has also used marijuana (Exhibits
B7F, B8F, and B16F). Additionally, the claimant’s medical records
indicate the claimant has been assessed with clinical examination
findings of an impaired memory, impaired concentration, a constricted
and anxious affect, anxious mood, nervous behavior, and anxious,
constricted, and irritable affect, a concrete thought content, variable
attention, fair insight, and fair judgment (Exhibits B8F and B16F).
(Tr. 21).
In particular, at his hearing before the ALJ, McCleary described a level of
anxiety and panic attacks which were so frequent and so severe that they left him
effectively paralyzed in terms of even simple decision making. (Tr. 59-62).
The clinical record, while extensive, was more complex and in some respects
contradictory. The longitudinal medical record of McCleary’s mental impairments
revealed a lengthy treatment history. In some instances, the clinical findings were
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relatively unremarkable; 	on 	other occasions 	they 	were grave. However, this
treatment history contained entries documenting anxiety, depression, visual and
auditory hallucinations, some paranoid thought processes, and instances of suicidal
ideation.
Thus, a psychiatric evaluation conducted by the Pennsylvania Psychiatric
Institute on April 15, 2021, noted that McCleary reported childhood abuse, paranoid
thinking, anxiety, depression and hallucinations. (Tr. 544-546). He also had a family
history of violence and self-harm. McCleary’s mother had reportedly attempted
suicide; his father was incarcerated for murder. (Id.)
Subsequent nursing notes of periodic medication maintenance encounters at
the Pennsylvania Psychiatric Institute between 2021 and 2023 were generally
unremarkable,2 however, these notes also indicated that McCleary continued to
experience hallucinations, hypervigilance and paranoia. (Tr. 917). His progress in
treatment was described as minimal in many areas. (Tr. 913-15). The most benign
aspects of these notes, in turn, were contradicted by the reports of McCleary’s
counselor at the Pennsylvania Psychiatric Institute, Francis Montresor, LSW, who
twice stated that McCleary experienced marked impairments in multiple spheres of
2 Tr. 554-55, 558-59, 561, 562-63, 567, 571, 580, 904-05, 909.
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workplace conduct, would often be off task, and would frequently miss work. (Tr.
1013-19, 1023-26).
Other caregivers provided a mixed picture concerning McCleary’s mental
state. Wellspan Internal Medicine treatment records of the plaintiff’s treatment in
2022 and 2023, consistently reported that McCleary suffered from hallucinations
and weekly panic attacks, (Tr. 797, 809, 823, 829-30), while indicating that he was
oriented in terms of times, people and places. (Tr. 801, 806, 813, 827, 834, 842). In
April of 2022, these records indicated that McCleary was unable to hold a job and
was permanently disabled because of his generalized anxiety disorder. (Tr. 614).
The severity of these symptoms were also documented on August 1, 2022 by
a consultative examiner, Dr. John Kajic, who described McCleary’s emotional state
in the following terms:
He reports difficulty falling asleep with frequent awakening and 1
appetite to be normal. Depressive symptomatology: Crying spells,
hopelessness, loss of usual interests, irritability, fatigue and loss of
energy, diminished self-esteem, concentration difficulties, diminished
sense of pleasure, and social withdrawal. Suicidal and homicidal
ideation, plans, intents, or means were denied at this time. Anxiety-
related symptomatology: Excessive apprehension and worry, easily
fatigued, irritability, fear of being judged or negatively evaluated in
social 	settings, 	avoidance 	of 	social 	settings, 	and 	difficulty
concentrating. Phobic responses: Around crowds and in close spaces.
Trauma experiences: Physically and/or sexually abused as a child, had
guns pulled on, had knives pulled on him, has been robbed, has been
mugged, has been in car accidents- Exposure to trauma: Flashbacks,
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hyperstartle 	response, 	nightmares, 	hypervigilance, 	avoidance,
intrusive thoughts, anger outbursts, detachment from others, and sleep
disturbances. The claimant reports he has had at least 10 significant
panic attacks leading to medical intervention. Triggers: Unknown. He
gets palpitations, nausea, sweating, dizziness, breathing difficulties,
trembling, and chest pain. Manic symptomatology: Denied. Thought
disorders: When asked about auditory or visual hallucinations, he said,
“sometimes I sees shadow figures out of the corner of my L eye and
when I’m trying to fall asleep when it is very silent I start to hear music
when no music is playing” He said this has been going on for about
five or six years. He says he feels like people are following him
watching him, or out to get him based on his past experiences. Other
symptoms of obsessions and compulsions: He reports when he is
anxious 	he 	uses 	medical 	marijuana 	to 	calm 	down. 	Cognitive
symptomatology: 	short-term 	memory 	deficits 	and 	concentration
difficulties.
(Tr. 531-532).
In 	May 	of 	2023, 	McCleary 	commenced 	mental 	health 	treatment 	with
Wellspan Philhaven. At that time, his clinical history and symptoms were stated that:
Fred identifies a history of Major depressive disorder, Generalized
anxiety disorder, Obsessive Compulsive disorder, Attention-deficit
hyperactivity disorder, Post-traumatic stress disorder, and Intermittent
explosive 	disorder. 	Fred 	reports 	struggling 	with 	mental 	health
throughout his entire life. He identifies an extensive trauma history in
childhood. 	His 	father 	was 	arrested 	for 	murder 	and 	is 	currently
incarcerated for life. His mother had difficulty providing for him and at
one point they were living out of a hearse during the winter months.
Fred's grandparents came and got him and he ended up being raised by
them. Fred's grandfather was physically and verbally abusive. Fred
grew up in York City and also experienced traumatic incidences while
living there. He was shot at once as a teenager, had two guns pulled on
him on another occasion, and was also witnessed someone being killed
on his street. Fred began receiving mental health treatment in 2008. He
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has had services through WS Philhaven in the past. He switched to PPI
as his therapists at Philhaven kept leaving.
His current therapist is now leaving PPI and the drive is also too far for
him. 	Fred 	would 	like 	to 	establish 	both 	outpatient 	therapy 	and
medication 	management 	through 	WS 	Philhaven. 	Fred 	was 	first
diagnosed with Bipolar disorder in 2008 by Dr. Zimberg at WellSpan
Philhaven. He later received neuropsychological testing and it was
determined he did not have Bipolar disorder, but rather ADHD. Fred
denies any symptoms of mania. Fred reports an increase in anxiety and
depression over the last two months. He has no known trigger or
stressor. He reports labile moods with irritability. He is very anxious
and feels depressed overall. Fred endorses symptoms of anxiety
including excessive worry, nervousness, racing thoughts, restlessness,
poor concentration, irritability, mind going blank, and trouble falling
and staying asleep at night. He is often too anxious to go out in public
and will avoid leaving the house. If he is alone in public he becomes on
edge and afraid. He does believe this is part of his PTSD. He is
constantly looking over his shoulder and is hypervigilant. He reports
when he is anxious he has difficulty calming down and worries he will
become angry. When angry he will yell, scream, and have irrational
thoughts. This is mostly directed toward his girlfriend. He will break or
throw items in the home every 3-4 months. Fred reports having panic
attacks every few days or weeks lasting 5-10 minutes. Fred endorses
symptoms of depression including loss of interest in doing things,
anhedonia, 	feelings 	of 	worthlessness 	and 	guilt, 	perceived
burdensomeness, decreased appetite, slow movement, trouble making
decisions, and suicidal ideation. Fred reports thoughts of suicide with a
method of stabbing himself. He denies having a plan or intent to act on
his thoughts. Fred denies homicidal ideation, method, plan, or intent.
Fred has been taking Prozac for about 3 months and Buspar for a few
years. He reports these are both ineffective.
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(Tr. 	962). 	Subsequent 	treatment 	notes 	from 	May 	through 	September 	2023
consistently 	documented 	racing 	and 	suicidal 	thoughts, 	recurrent, 	repetitive
behaviors, and auditory hallucinations. (Tr. 926-51).
Given this complex clinical history, the medical opinion evidence was
particularly significant in determining whether McCleary’s multiple emotional
impairments were wholly disabling. On this score, three sources opined regarding
the gravity of McCleary’s mental state.
First, 	McCleary’s 	treating 	counselor, 	Francis 	Montresor, 	LSW, 	twice
submitted medical questionnaires in February 2022, (Tr. 1013-19), and December
2023. (Tr. 1023-26). In these questionnaires, LSW Montresor consistently described
McCleary’s impairments as disabling. According to Montresor, McCleary suffered
from depression, anxiety, PTSD, intermittent explosive disorder and ADHD. (Tr.
1013). These impairments markedly impaired McCleary’s ability to make simple
work decisions, complete a workday, work with others, and adapt to workplace
changes. (Tr. 1015-16, 1024-26). LSW Montresor stated that these emotional
limitations would impede McCleary’s ability to stay on task and would result in
excessive absenteeism at work. (Tr. 1017, 1026). His prognosis was deemed poor.
(Tr. 1023).
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In contrast, two non-treating, non-examining state agency sources reached
very different conclusions based upon the same clinical record. Yet, the opinions of
these state agency sources were internally inconsistent in ways that were seemingly
unrecognized by either the experts or the ALJ. In an August 2022 initial assessment
by Dr. Emanuel Schnepp, and a January 2023 reconsideration evaluation by Dr.
Melissa Franks, these experts reached two irreconcilable determinations, finding that
McCleary had mild limitations on his ability to understand and apply information,
but only had the mental capacity to manage, understand, and complete simple one-
or two-step tasks. 	(Tr. 121, 128, 134, 140). These findings are inherently
contradictory since, under the Dictionary of Occupational Titles, the ability to
perform one-to-two-step tasks confines a worker to reasoning level 1 jobs, the most
severe restriction on workplace reasoning. See Dictionary of Occupational Titles,
Appendix C - Components of the Definition Trailer, 1991 WL 688702. Therefore, a
one-to-two-step 	functional 	capacity 	cannot 	be 	readily 	reconciled 	with 	mild
impairments in understanding and applying information.
One other expert, a consulting examining source, Dr. John Kajic, also opined
regarding the degree of impairment experienced by McCleary, albeit in a somewhat
contradictory fashion. Dr. Kajic’s report documented multiple impairments on
McCleary’s part including phobic responses, multiple panic attacks requiring
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medical intervention, hallucinations, memory deficits and concentration difficulties.
(Tr. 531-532). Yet, while Dr. Kajic endorsed this constellation of severe symptoms,
he opined that McCleary experienced no limitations on understanding simple
instructions. (Tr. 535).
C. The ALJ Hearing and Decision
It was against this medical backdrop that McCleary’s disability claim came to
be heard by the ALJ on December 6, 2023, at which McCleary and a Vocational
Expert (VE) testified. (Tr. 49-69). McCleary’s testimony described the emotionally
paralyzing effect of his anxiety in terms of his decision-making ability. (Tr. 59-62).
The VE, in turn, testified that McCleary could perform tasks which entailed a
reasoning level of 2, but was never asked to reconcile this testimony with the state
agency expert opinions which appeared to state that McCleary could only perform
one-to-two-step tasks. (Tr. 64-67).
Following this hearing, on March 1, 2024, the ALJ issued a decision denying
McCleary’s application for benefits. (Tr. 7-29). In that decision, the ALJ first
concluded that the plaintiff last met the insured status requirements of the Social
Security Act on December 31, 2022, and had not engaged in substantial gainful
activity since February 24, 2021, the alleged onset date. (Tr. 13). At Step 2 of the
sequential analysis that governs Social Security cases, the ALJ found that McCleary
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had the following severe impairments: degenerative disc disease of the lumbar spine
and cervical spine, osteoarthritis of the knees, mild tricompartmental marginal
spurring of the right ankle, obesity, depression, anxiety, post-traumatic stress
disorder, 	bipolar 	disorder, 	substance 	use 	disorder 	(marijuana 	use), 	obsessive
compulsive disorder, attention deficit hyperactivity disorder, intermittent explosive
disorder, and personality disorder. (Id.)
At Step 3, the ALJ determined that these impairments did not meet or
medically equal the severity of any listed impairments. (Tr. 13-18). However, in
reaching 	this 	conclusion, 	the 	ALJ 	made 	findings 	regarding 	the 	severity 	of
McCleary’s mental impairments which were ultimately at odds with the medical
opinions deemed persuasive by the ALJ. Specifically, the ALJ found that:
In understanding, remembering or applying information, the claimant
has a moderate limitation. The claimant has alleged experiencing
symptoms of auditory and visual hallucinations, racing thoughts, and
short-term memory deficits (Exhibits B7F and B8F). He alleges having
a 	hard 	time 	following 	instructions, 	he 	cannot 	remember 	written
instructions, 	he 	has 	trouble 	remembering 	instructions, 	he 	needs
reminders for appointments, he needs help or reminders to take
medication, he needs reminders to go places, and he is not able to pay
bills, handle a savings account, or use a checkbook/money orders
(Exhibit B5E). The claimant’s medical records indicate the claimant
has been assessed with clinical examination findings of an impaired
memory and a concrete thought content (Exhibits B8F and B16F).
(Tr. 16).
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Between Steps 3 and 4, the ALJ fashioned a residual functional capacity
(“RFC”), considering the plaintiff’s limitations from his impairments, stating that:
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) occasionally
climb ramps/stairs, balance, stoop, kneel, crouch, and crawl; never
climb 	ladders, 	ropes, 	scaffolds 	or 	work 	at 	unprotected 	heights;
frequently reach front/lateral, handle, finger, feel, push, and pull
bilaterally; 	occasionally 	overhead 	reach 	bilaterally; 	can 	tolerate
occasional exposure to operating motor vehicles, contact with moving
mechanical parts, temperature extremes, humidity, wetness, vibration,
concentrated 	dust, 	fumes, 	or 	gases; 	can 	maintain 	concentration,
persistence, or pace for two hour segments sufficient to perform routine
two to three step tasks or instructions; can frequently interact with
public, supervisors, or coworkers; can frequently perform team or
tandem type work; and can perform work that involves no more than
frequent changes in work situations in a routine work setting.
(Tr. 18-19) (emphasis added).
This RFC was unmoored from any of the medical opinions deemed persuasive
by the ALJ; moreover, the medical opinions which the ALJ found persuasive were
internally inconsistent, were inconsistent with one another, and were inconsistent
with the ALJ’s findings.
At the outset, the ALJ 	rejected 	the treating 	source opinions 	of LSW
Montresor, which concluded that McCleary often experienced moderate to marked
impairment, finding them unpersuasive. (Tr. 26). The ALJ did not reconcile the
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rejection of this medical opinion with his own determination that McCleary was
moderately impaired in mental functioning.
As for the state agency expert opinions, the ALJ, stated that:
State agency psychological consultants completed opinions on August
12, 2022 and January 13, 2023 that indicate the claimant has some
moderate limitations pertaining to social interaction and sustained
concentration 	and 	persistence. 	The 	State 	agency 	psychological
consultants also completed psychiatric review techniques that indicate
the claimant has an overall mild degree of limitation pertaining to
understanding, remembering, or applying information and adapting or
managing 	oneself 	and 	an 	overall 	moderate 	degree 	of 	limitation
regarding interacting with others and concentrating, persistence, or
maintaining pace, (Exhibits B4A, B5A, B8A, and B9A). In support of
the opinions, the State agency psychological consultant provided
explanatory comments that include references to symptoms pertaining
to the claimant’s mental impairments. Additionally, the opinions of the
State 	agency 	psychological 	consultant 	are 	consistent 	with 	the
claimant’s medical records on a longitudinal basis, including clinical
examination findings of normal speech, a normal thought content, a
euthymic mood, an intact memory, normal motor activity, a normal
thought process, an intact long-term memory, an intact immediate
memory, an intact short-term memory, appropriate eye contact, a
cooperative 	manner, 	intact 	concentration, 	intact 	insight, 	intact
judgment, and a euthymic mood and notations in the claimant’s medical
records indicating the claimant denied experiencing any mental health
symptoms and the claimant reported he is socializing appropriately.
However, the aspects of the State agency psychological consultants’
opinions 	pertaining 	to 	understanding, 	remembering, 	or 	applying
information and adapting or managing oneself do not adequately
consider 	symptoms 	and 	abnormal 	clinical 	examination 	findings
pertaining to understanding, remembering, or applying information and
adapting or managing oneself. Thus, the undersigned only finds the
opinions 	of 	the 	State 	agency 	psychological 	consultants 	partially
persuasive, 	specifically 	noting 	the 	aspects 	of 	the 	State 	agency
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psychological 	consultants’ 	opinions 	pertaining 	to 	understanding,
remembering, or applying information and adapting or managing
oneself are not persuasive.
(Tr. 24).
The ALJ’s treatment of these opinions was notable in several respects. First,
the ALJ made no mention of the one-to-two-step limitations contained in those
opinions. Thus, the ALJ seemingly failed to recognize the inherent tension between
this aspect of the experts’ reports and their findings that McCleary was only mildly
limited in applying information beyond acknowledging that the reports “do not
adequately 	consider 	symptoms 	and 	abnormal 	clinical 	examination 	findings
pertaining to understanding, remembering, or applying information and adapting or
managing oneself.” (Id.) In this regard, the ALJ plainly suggested that, in terms of
following instructions, McCleary suffered from greater mental limitations than those
described by the state agency experts. Yet, paradoxically, the ALJ then assigned
greater persuasive power to Dr. Kajic’s medical opinion which found that McCleary
“has no limitations pertaining to understanding, remembering, and carrying out
simple instructions.” (Tr. 23). This inconsistency also remained unexplained by the
ALJ.
Having made these findings, the ALJ concluded that McCleary could not
return to his past work but could perform other work in the national economy, which
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were SVP-2 occupations that exceeded the one-to-two-step task mental limitations
found by the state agency experts.(Tr. 27-28). The ALJ then determined 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, McCleary contends, inter alia, that
the ALJ’s mental RFC evaluation was flawed. After a review of the evidence, we
agree that the ALJ’s adoption of a less restrictive limitation of two-to-three-step
instructions was divorced from any medical opinion, coupled with the ALJ’s overall
treatment of the medical opinion evidence, does not provide us an adequate factual,
legal and logical bridge between the evidence and the ALJ’s ultimate decision
denying benefits. 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
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).
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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-
evidence standard, a court looks to an existing administrative record
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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
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 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).
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.
This principle applies with particular force to legal challenges, like the claim
made here, based 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
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
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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
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
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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
impairments identified by the ALJ at step two of his or her analysis. 	20 C.F.R.
§404.1545(a)(2).
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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
physician is misguided.” Cummings v. Colvin, 129 F. Supp. 3d 209, 214–15 (W.D.
Pa. 2015).
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These 	seemingly 	discordant 	legal 	propositions 	can 	be 	reconciled 	by
evaluation of the factual context of these decisions. Those cases which emphasize
the importance of medical opinion support for an RFC assessment typically arise in
the factual setting 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
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
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*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
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
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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. Legal Benchmarks for the ALJ’s Assessment of Medical Opinions
The plaintiff filed this disability application following a paradigm shift in the
manner in which medical opinions were evaluated when assessing Social Security
claims. Prior to March 2017, ALJs were required to follow regulations which defined
medical opinions narrowly and created a hierarchy of medical source opinions with
treating sources at the apex of this hierarchy. However, in March of 2017, the
Commissioner’s regulations governing medical opinions changed in a number of
fundamental ways. The range of opinions that ALJs were enjoined to consider were
broadened substantially, and the approach to evaluating opinions was changed from
a hierarchical form of review to a more holistic analysis. As one court as aptly
observed:
The regulations regarding the evaluation of medical evidence have been
amended for claims filed after March 27, 2017, and several of the prior
Social Security Rulings, including SSR 96-2p, have been rescinded.
According to the new regulations, the Commissioner “will no longer
give any specific evidentiary weight to medical opinions; this includes
giving controlling weight to any medical opinion.” Revisions to Rules
Regarding the Evaluation of Medical Evidence (“Revisions to Rules”),
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2017 WL 168819, 82 Fed. Reg. 5844, at 5867–68 (Jan. 18, 2017), see
20 C.F.R. §§ 404.1520c(a), 416.920c(a). Instead, the Commissioner
must consider all medical opinions and “evaluate their persuasiveness”
based 	on 	the 	following 	five 	factors: 	supportability; 	consistency;
relationship with the claimant; specialization; and “other factors.” 20
C.F.R. §§ 404.1520c(a)-(c), 416.920c(a)-(c).
Although the new regulations eliminate the perceived hierarchy of
medical sources, deference to specific medical opinions, and assigning
“weight” to a medical opinion, the ALJ must still “articulate how [he
or she] considered the medical opinions” and “how persuasive [he or
she] find[s] all of the medical opinions.” Id. at §§ 404.1520c(a) and
(b)(1), 416.920c(a) and (b)(1). The two “most important factors for
determining the persuasiveness of medical opinions are consistency and
supportability,” 	which 	are 	the 	“same 	factors” 	that 	formed 	the
foundation of the treating source rule. Revisions to Rules, 82 Fed. Reg.
5844-01 at 5853.
An ALJ is specifically required to “explain how [he or she] considered
the supportability and consistency factors” for a medical opinion. 20
C.F.R. 	§§ 	404.1520c 	(b)(2), 	416.920c(b)(2). 	With 	respect 	to
“supportability,” the new regulations provide that “[t]he more relevant
the objective medical evidence and supporting explanations presented
by a medical source are to support his or her medical opinion(s) or prior
administrative medical finding(s), the more persuasive the medical
opinions or prior administrative medical finding(s) will be.” Id. at §§
404.1520c(c)(1), 416.920c(c)(1). The regulations provide that with
respect to “consistency,” “[t]he more consistent a medical opinion(s) or
prior administrative medical finding(s) is with the evidence from other
medical sources and nonmedical sources in the claim, the more
persuasive the medical opinion(s) or prior administrative medical
finding(s) will be.” Id. at §§ 404.1520c(c)(2), 416.920c(c)(2).
Under the new regulations an ALJ must consider, but need not
explicitly discuss, the three remaining factors in determining the
persuasiveness of a medical source's opinion. Id. at §§ 404.1520c(b)(2),
416.920c(b)(2). However, where the ALJ has found two or more
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medical opinions to be equally well supported and consistent with the
record, but not exactly the same, the ALJ must articulate how he or she
considered those factors contained in paragraphs (c)(3) through (c)(5).
Id. at §§ 404.1520c(b)(3), 416.920c(b)(3).
Andrew G. v. Comm'r of Soc. Sec., No. 3:19-CV-0942 (ML), 2020 WL 5848776, at
*5 (N.D.N.Y. Oct. 1, 2020).
Oftentimes, as in this case, an ALJ must evaluate various medical opinions.
When presented with a disputed factual record, it is well-established that “[t]he ALJ
– not treating or examining physicians or State agency consultants – must make the
ultimate disability and RFC determinations.” Chandler v. Comm’r of Soc. Sec., 667
F.3d 356, 361 (3d Cir. 2011). However, the ALJ must still fully articulate the basis
of this medical opinion evaluation. Thus, when evaluating medical opinions “the
ALJ may choose whom to credit but ‘cannot reject evidence for no reason or for the
wrong reason.’” Morales v. Apfel, 225 F.3d 310, 317 (3d Cir. 2000) (quoting Mason,
994 F.2d at 1066). It also follows that “when a medical opinion is found persuasive
and contains a limitation to one- and two-step tasks, the ALJ is obligated to either:
(1) include the limitation in the RFC and limit the claimant to reasoning level one
occupations, or, (2) identify the substantial evidence that the ALJ is relying on in
rejecting the limitation.” Cruz, 2025 WL 2813882, at *8.
These legal benchmarks guide us in the instant case.
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D. This Case Will Be Remanded.
After a review of the record, we conclude that the ALJ’s attempt to navigate
the complex clinical record and contradictory medical opinions in this case has
failed. In reaching this conclusion we find ourselves at the intersection between two
well-settled paradigms in the Social Security field. First, our highly deferential
standard of review empowers “[t]he ALJ – not treating or examining physicians or
State 	agency 	consultants 	– 	[to] 	make 	the 	ultimate 	disability 	and 	RFC
determinations.” Chandler, 667 F.3d at 361. Thus, our decision in this case in no
way undercuts the legal tenet that an ALJ is not required to adopt every limitation
opined by the experts but “can formulate an RFC based on different parts from the
different medical opinions.” Durden, 191 F.Supp.3d at 455. However, at base, an
ALJ must draft a reviewable opinion that is grounded in the evidence and provides
the court with an adequately articulated and well-reasoned rationale for the
limitations adopted.
Here, the internal inconsistencies in the ALJ’s evaluation of the medical
opinion evidence and the adoption of a two-to-three-step instruction limitation in the
RFC fail to meet this basic standard of articulation. Indeed, this analysis is flawed in
the following significant respects.
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First, the ALJ failed to fully reconcile the rejection of the treating source
opinions—which 	found 	that 	McCleary 	suffered 	from 	moderate 	to 	marked
impairments—with the ALJ’s decision that the plaintiff was moderately impaired in
all spheres of intellectual activity in the workplace.
Second, the ALJ failed to analyze, address or even fully acknowledge the
internal inconsistencies in the state agency opinions which casually conflated mild
mental impairments with an RFC that restricted McCleary to one-to-two-step tasks.
This was error and is a persistent form of error which has led to multiple remands in
this past.3
Third, the ALJ found that the state agency reports “do not adequately consider
symptoms and abnormal clinical examination findings pertaining to understanding,
remembering, or applying information and adapting or managing oneself,” (tr. 24),
plainly suggesting that, in terms of following instructions, McCleary suffered from
3 See e.g., Whitney v. Bisignano, No. 4:24-CV-1950, 2026 WL 522922, at *10 (M.D.
Pa. Feb. 25, 2026); 	Cruz v. Bisignano, No. 1:24-CV-1966, 2025 WL 2813882, at
*7 (M.D. Pa. Sept. 30, 2025); Michelle M. v. Bisignano, No. 3:23-CV-02163, 2025
WL 2713737, at *7 (M.D. Pa. Sept. 23, 2025); Warren v. Dudek, No. 1:24-CV-635,
2025 WL 1168276, at *6 (M.D. Pa. Apr. 22, 2025); Shipman v. Kizakazi, No. 3:22-
CV-00636, 2023 WL 5599607, at *10 (M.D. Pa. Aug. 29, 2023).
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greater mental limitations than those described by the state agency experts. Yet,
paradoxically, the ALJ then assigned greater persuasive power to Dr. Kajic’s
medical opinion which found that McCleary “has no limitations pertaining to
understanding, remembering, and carrying out simple instructions.” (Tr. 23). This
inconsistency was unexplained by the ALJ.
Finally, the mental RFC crafted by the ALJ—which found that he can
maintain concentration, persistence, or pace for two-hour segments sufficient to
perform routine two-to-three-step tasks or instructions—was unmoored to any of the
medical opinions found persuasive by the ALJ, and seemingly found that he could
do more than the state agency experts opined, even though the ALJ concluded that
those state agency experts had overstated McCleary’s ability to apply information.
We have in the past opined that this type of ad hoc mental RFC formulation fails as
a matter of law. Matos v. Bisignano, No. 4:24-CV-675, 2025 WL 2918975, at *12
(M.D. Pa. Oct. 10, 2025). So it is in this case as well.
Simply put, given these compounding contradictions more was needed here
by way of explanation on the ALJ’s part. Since the ALJ’s burden of articulation is
not met in the instant case, this matter will be remanded for further consideration by
the Commissioner. 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
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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 since “[a] remand may produce 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).
Finally, we close as we began, by observing that one root cause of this remand
is an issue which courts have repeatedly observed, the apparent failure of legal and
medical professionals to attach a common meaning to the words they use. Thus, we
note for the Commissioner that the casual conflation of one-to-two-step RFCs in
medical opinions with widely varying opinions regarding the claimant’s degree of
impairment, if unaddressed, will continue to compel remands in the future.
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.
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s/ Martin C. Carlson
Martin C. Carlson
United States Magistrate Judge
DATED: March 5, 2026
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