Opinions and documents
UNITED STATES DISTRICT COURT
DISTRICT OF NEW JERSEY
ANNAMARIE S.,1
Plaintiff,
Case No. 1:24-cv-6638
v. Magistrate Judge Norah McCann King
FRANK BISIGNANO,2
Commissioner of Social Security,
Defendant.
OPINION AND ORDER
This matter comes before the Court pursuant to Section 205(g) of the Social Security Act,
as amended, 42 U.S.C. § 405(g), regarding the application of Plaintiff Annamarie S. for
Disability Insurance Benefits under Title II of the Social Security Act, 42 U.S.C. §§ 401 et seq.
Plaintiff appeals from the final decision of the Commissioner of Social Security denying that
application. After careful consideration of the entire record, including the entire administrative
record, the Court decides this matter pursuant to Rule 78(b) of the Federal Rules of Civil
Procedure. For the reasons that follow, the Court affirms the Commissioner’s decision.
I. PROCEDURAL HISTORY
On October 7, 2020, Plaintiff filed her application for benefits, alleging that she has been
disabled since May 6, 2016. R. 62, 77, 208–09. The application was denied initially and upon
1 The Committee on Court Administration and Case Management of the Judicial Conference of
the United States has recommended that, due to significant privacy concerns in social security
cases, federal courts should refer to plaintiffs in such cases by only their first names and last
initials. See also D.N.J. Standing Order 2021-10.
2 Frank Bisignano, the current Commissioner of Social Security, is substituted as Defendant in
his official capacity. See Fed. R. Civ. P. 25(d).
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reconsideration. R. 84–87, 89–92. Plaintiff sought a de novo hearing before an administrative
law judge (“ALJ”). R. 93–94. ALJ Elizabeth Lardaro held a hearing on April 17, 2023, at which
Plaintiff, who was represented by counsel, testified, as did a vocational expert. R. 43–61. In a
decision dated June 1, 2023, the ALJ concluded that Plaintiff was not disabled within the
meaning of the Social Security Act at any time from May 6, 2016, Plaintiff’s alleged disability
onset date, through December 31, 2021, the date on which Plaintiff was last insured for
Disability Insurance Benefits. R. 19–37. That decision became the final decision of the
Commissioner of Social Security when the Appeals Council declined review on April 15, 2024.
R. 1–7. Plaintiff timely filed this appeal pursuant to 42 U.S.C. § 405(g). ECF No. 1. On February
14, 2025, Plaintiff consented to disposition of the matter by a United States Magistrate Judge
pursuant to 28 U.S.C. § 636(c) and Rule 73 of the Federal Rules of Civil Procedure. ECF No.
18.3 On February 28, 2025, the case was reassigned to the undersigned. ECF No. 19. The matter
is ripe for disposition.
II. LEGAL STANDARD
A. Standard of Review
In reviewing applications for Social Security disability benefits, this Court has the
authority to conduct a plenary review of legal issues decided by the ALJ. Knepp v. Apfel, 204
F.3d 78, 83 (3d Cir. 2000). In contrast, the Court reviews the ALJ’s factual findings to
determine if they are supported by substantial evidence. Sykes v. Apfel, 228 F.3d 259, 262 (3d
Cir. 2000); see also 42 U.S.C. § 405(g). The United States Supreme Court has explained this
standard as follows:
3The Commissioner has provided general consent to Magistrate Judge jurisdiction in cases
seeking review of the Commissioner’s decision. See Standing Order In re: Social Security Pilot
Project (D.N.J. Apr. 2, 2018).
2
Under the substantial-evidence standard, a court looks to an existing administrative
record and asks whether it contains sufficien[t] evidence to support the agency’s
factual determinations. 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. It means – and means only – such
relevant evidence as a reasonable mind might accept as adequate to support a
conclusion.
Biestek v. Berryhill, 587 U.S. 97, 102–03 (2019) (internal citations and quotation marks omitted);
see also Pierce v. Underwood, 487 U.S. 552, 565 (1988) (citation and internal quotations
omitted); Bailey v. Comm’r of Soc. Sec., 354 F. App’x 613, 616 (3d Cir. 2009) (citations and
quotations omitted); K.K. ex rel. K.S. v. Comm’r of Soc. Sec., No. 17-2309, 2018 WL 1509091,
at *4 (D.N.J. Mar. 27, 2018).
The substantial evidence standard is a deferential standard, and the ALJ’s decision cannot
be set aside merely because the Court “acting de novo might have reached a different
conclusion.” Hunter Douglas, Inc. v. NLRB, 804 F.2d 808, 812 (3d Cir. 1986); see, e.g., Fargnoli
v. Massanari, 247 F.3d 34, 38 (3d Cir. 2001) (“Where the ALJ’s findings of fact are supported
by substantial evidence, we are bound by those findings, even if we would have decided the
factual inquiry differently.”) (citing Hartranft v. Apfel, 181 F.3d 358, 360 (3d Cir. 1999)); K.K.,
2018 WL 1509091, at *4 (“‘[T]he district court ... is [not] empowered to weigh the evidence or
substitute its conclusions for those of the fact-finder.’”) (quoting Williams v. Sullivan, 970 F.2d
1178, 1182 (3d Cir. 1992)).
Nevertheless, the Third Circuit cautions that this standard of review is not “a talismanic
or self-executing formula for adjudication.” Kent v. Schweiker, 710 F.2d 110, 114 (3d Cir. 1983)
(“The search for substantial evidence is thus a qualitative exercise without which our review of
social security disability cases ceases to be merely deferential and becomes instead a sham.”);
see Coleman v. Comm’r of Soc. Sec., No. 15-6484, 2016 WL 4212102, at *3 (D.N.J. Aug. 9,
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2016). The Court has a duty to “review the evidence in its totality” and “take into account
whatever in the record fairly detracts from its weight.” K.K., 2018 WL 1509091, at *4 (quoting
Schonewolf v. Callahan, 972 F. Supp. 277, 284 (D.N.J. 1997) (citations and quotations omitted));
see Cotter v. Harris, 642 F.2d 700, 706 (3d Cir. 1981) (stating that substantial evidence exists
only “in relationship to all the other evidence in the record”). Evidence is not substantial if “it is
overwhelmed by other evidence,” “really constitutes not evidence but mere conclusion,” or
“ignores, or fails to resolve, a conflict created by countervailing evidence.” Wallace v. Sec’y of
Health & Human Servs., 722 F.2d 1150, 1153 (3d Cir. 1983) (citing Kent, 710 F.2d at 114); see
K.K., 2018 WL 1509091, at *4. The ALJ’s decision thus must be set aside if it “did not take into
account the entire record or failed to resolve an evidentiary conflict.” Schonewolf, 972 F. Supp.
at 284-85 (citing Gober v. Matthews, 574 F.2d 772, 776 (3d Cir. 1978)).
Although an ALJ is not required “to use particular language or adhere to a particular
format in conducting [the] analysis,” the decision must contain “sufficient development of the
record and explanation of findings to permit meaningful review.” Jones v. Barnhart, 364 F.3d
501, 505 (3d Cir. 2004) (citing Burnett v. Comm’r of Soc. Sec., 220 F.3d 112, 119 (3d Cir.
2000)); see K.K., 2018 WL 1509091, at *4. The Court “need[s] from the ALJ not only an
expression of the evidence s/he considered which supports the result, but also some indication of
the evidence which was rejected.” Cotter, 642 F.2d at 705-06; see Burnett, 220 F.3d at 121
(“Although the ALJ may weigh the credibility of the evidence, [s/]he must give some indication
of the evidence which [s/]he rejects and [the] reason(s) for discounting such evidence.”) (citing
Plummer v. Apfel, 186 F.3d 422, 429 (3d. Cir. 1999)). “[T]he ALJ is not required to supply a
comprehensive explanation for the rejection of evidence; in most cases, a sentence or short
paragraph would probably suffice.” Cotter v. Harris, 650 F.2d 481, 482 (3d Cir. 1981). Absent
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such articulation, the Court “cannot tell if significant probative evidence was not credited or
simply ignored.” Id. at 705. As the Third Circuit explains:
Unless the [ALJ] has analyzed all evidence and has sufficiently explained the
weight [s/]he has given to obviously probative exhibits, to say that [the] decision is
supported by substantial evidence approaches an abdication of the court’s duty to
scrutinize the record as a whole to determine whether the conclusions reached are
rational.
Gober, 574 F.2d at 776; see Schonewolf, 972 F. Supp. at 284-85.
Following review of the entire record on appeal from a denial of benefits, the Court can
enter “a judgment affirming, modifying, or reversing the decision of the [Commissioner], with or
without remanding the cause for a rehearing.” 42 U.S.C. § 405(g). Remand is appropriate if the
record is incomplete or if the ALJ’s decision lacks adequate reasoning or contains illogical or
contradictory findings. See Burnett, 220 F.3d at 119-20; Podedworny v. Harris, 745 F.2d 210,
221-22 (3d Cir. 1984). Remand is also appropriate if the ALJ’s findings are not the product of a
complete review which “explicitly weigh[s] all relevant, probative and available evidence” in the
record. Adorno v. Shalala, 40 F.3d 43, 48 (3d Cir. 1994) (internal quotation marks omitted); see
A.B. on Behalf of Y.F. v. Colvin, 166 F. Supp.3d 512, 518 (D.N.J. 2016).
B. Sequential Evaluation Process
The Social Security Act establishes a five-step sequential evaluation process for
determining whether a plaintiff is disabled within the meaning of the statute. 20 C.F.R. §
404.1520(a)(4). “The claimant bears the burden of proof at steps one through four, and the
Commissioner bears the burden of proof at step five.” Smith v. Comm’r of Soc. Sec., 631 F.3d
632, 634 (3d Cir. 2010) (citing Poulos v. Comm’r of Soc. Sec., 474 F.3d 88, 92 (3d Cir. 2007)).
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At step one, the ALJ determines whether the plaintiff is currently engaged in substantial
gainful activity. 20 C.F.R. § 404.1520(b). If so, then the inquiry ends because the plaintiff is not
disabled.
At step two, the ALJ decides whether the plaintiff has a “severe impairment” or
combination of impairments that “significantly limits [the plaintiff’s] physical or mental ability
to do basic work activities[.]” 20 C.F.R. § 404.1520(c). If the plaintiff does not have a severe
impairment or combination of impairments, then the inquiry ends because the plaintiff is not
disabled. Otherwise, the ALJ proceeds to step three.
At step three, the ALJ decides whether the plaintiff’s impairment or combination of
impairments “meets” or “medically equals” the severity of an impairment in the Listing of
Impairments (“Listing”) found at 20 C.F.R. § 404, Subpart P, Appendix 1. 20 C.F.R. §
404.1520(d). If so, then the plaintiff is presumed to be disabled if the impairment or combination
of impairments has lasted or is expected to last for a continuous period of at least 12 months. Id.
at § 404.1509. Otherwise, the ALJ proceeds to step four.
At step four, the ALJ must determine the plaintiff’s residual functional capacity (“RFC”)
and determine whether the plaintiff can perform past relevant work. 20 C.F.R. § 404.1520(e), (f).
If the plaintiff can perform past relevant work, then the inquiry ends because the plaintiff is not
disabled. Otherwise, the ALJ proceeds to the final step.
At step five, the ALJ must decide whether the plaintiff, considering the plaintiff’s RFC,
age, education, and work experience, can perform other jobs that exist in significant numbers in
the national economy. 20 C.F.R. § 404.1520(g). If the ALJ determines that the plaintiff can do
so, then the plaintiff is not disabled. Otherwise, the plaintiff is presumed to be disabled if the
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impairment or combination of impairments has lasted or is expected to last for a continuous
period of at least twelve months.
III. ALJ DECISION AND APPELLATE ISSUES
At step one, the ALJ found that Plaintiff had not engaged in substantial gainful activity
between May 6, 2016, her alleged disability onset date, and December 31, 2021, her date last
insured. R. 21.
At step two, the ALJ found that Plaintiff’s diabetes, cervical degenerative disc disease
and radiculopathy, and lumbar degenerative disc disease and radiculopathy were severe
impairments. R. 21. The ALJ also found that the following impairments were not severe:
hypertension, hyperlipidemia, Hashimoto’s disease, carpal tunnel syndrome, obesity, and anxiety
disorder. R. 22–28.
At step three, the ALJ found that Plaintiff did not suffer an impairment or combination of
impairments that met or medically equaled the severity of any Listing. R. 28–29.
At step four and relying on the testimony of the vocational expert, the ALJ found that
Plaintiff had the RFC to perform sedentary work subject to various additional limitations. R. 29–
37. The ALJ also found that this RFC did not permit the performance of Plaintiff’s past relevant
work as a payroll clerk, accounting clerk, and “personal” clerk. R. 36–37. The ALJ therefore
concluded that Plaintiff was not disabled at any time within the meaning of the Social Security
Act from May 6, 2016, her alleged disability onset date, through December 31, 2021, the date on
which she was last insured for benefits. R. 37.
Plaintiff disagrees with the ALJ’s findings at steps two and four and asks that the decision
of the Commissioner be reversed and remanded with directions for the granting of benefits or,
alternatively, for further proceedings. Plaintiff’s Brief, ECF No. 8; Plaintiff’s Reply Brief, ECF
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No. 17. The Commissioner takes the position that his decision should be affirmed in its entirety
because the ALJ’s decision correctly applied the governing legal standards, reflected
consideration of the entire record, and was supported by sufficient explanation and substantial
evidence. Defendant’s Brief, ECF No. 16.
IV. SUMMARY OF RELEVANT MEDICAL EVIDENCE
A. State Agency Psychological Consultants
Robert Eckardt4 conducted an initial review of Plaintiff’s medical record on behalf of the
state agency on May 27, 2021. R. 63–69. Consultant Eckardt found that Plaintiff’s mental
disorders—depressive, bipolar and related disorders as well as anxiety and obsessive-compulsive
disorders—were not severe. R. 65. In conducting the psychiatric review technique (“PRT”) in
connection with the criteria of Listings 12.04 and 12.06, Consultant Eckardt concluded that
Plaintiff had medically determinable impairments, but that those impairments did not satisfy the
criteria for those listings. Id. Consultant Eckardt specifically opined that Plaintiff had only mild
limitations in the paragraph B criteria, namely, understanding, remembering, or applying
information; interacting with others; concentrating, persisting, or maintaining pace; and adapting
or managing oneself. Id. (finding further that the record did not document the “C” criteria of the
listings). Under the heading “PRT Additional Explanation[,]” Consultant Eckardt further
explained why Plaintiff’s mental impairments were not severe:
57 yr old female alleging physical ailments and anxiety. No inpt psych hx. PCP
prescribes xanax for anxiety. No formal psych hx prior to beginning therapy with
social worker a few months ago. 3/21 and 2/21 sessions reveal mental status is
entirely intact including euthymic mood. At Psych CE, she reported sx of
depression and anxiety. However, mental status was grossly within normal limits.
Report of sx is only partially consistent with findings. Consistent with her marginal
psych hx, there are no indications/findings of a severe psych impairment in file.
4 Other than his specialty of psychology, R. 65, Consultant Eckhardt’s credentials do not appear
in the record.
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Able to perform adls from a psych standpoint. Not Severe[.]
R. 65–66.
Amy Brams5 reviewed Plaintiff’s medical record upon reconsideration for the state
agency on August 5, 2021. R. 70–76. Consultant Brams agreed with Consultant Eckardt that,
inter alia, Plaintiff had non-severe medically determinable mental impairments of depressive,
bipolar and related disorders as well as anxiety and obsessive-compulsive disorders. R. 72. She
also agreed that Plaintiff had only a mild limitation in the four broad areas of functioning under
paragraph B. Id. (finding further that evidence did not establish the presence of the “C” criteria).
Under the heading “PRT Additional Explanation[,]” Consultant Brams agreed that Plaintiff’s
mental impairments were not severe, explaining as follows:
57 year old reconDI alleges too tired and in pain to do things, mood swings, think
straight, continues to express anxiety, Posttraumatic stress from MVA.
57 yr old female alleging physical ailments and anxiety. No inpt psych hx. PCP
prescribes xanax for anxiety. No formal psych hx prior to beginning therapy. with
social worker a few months ago. 3/21 and 2/21 sessions reveal mental status is
entirely intact including euthymic mood. At Psych CE, she reported sx of
depression and anxiety. However, mental status was grossly within normal limits.
Report of sx is only partially consistent with findings. Consistent with her marginal
psych hx, there are no indications/findings of a severe psych impairment in file.
Able to perform adls from a psych standpoint. Not Severe[.]
Recon: Updated MER 6/28/21; wants to be able to drive again, PCP suggested
therapy to learn to manage anxiety, is frustrated with pain, is agitated and angry.
Meds Xanax. Had disagrrement [sic] about expectation of therapy and ended
relationship late April. 6 sessions, was helped. MSE WNL except angry mood.
ADL; can manage money, sometimes drives short distances, sometimes shops in
stores, needs some reminders, gets along with authority figures.
Affirmation; not severe
R. 72–73.
5 As with Consultant Eckardt, Consultant Brams’ credentials, other than her psychology
specialty, R. 73, do not appear in the record.
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B. Thomas Godleski, D.O.
On October 3, 2022, Thomas Godleski, D.O., of Virtua Family Medicine, Plaintiff’s
treating physician, completed a three-page, check-the-box, and fill-in-the-blank “Medical Source
Statement.” R. 479–81. Dr. Godleski stated that he had treated Plaintiff for eleven years and he
diagnosed chronic lower back pain, panic disorder, post-traumatic stress disorder (“PTSD”), and
Type 2 diabetes mellitus. R. 479. According to Dr. Godleski, Plaintiff had the following
symptoms/signs: musculoskeletal pain (lower back / lumbar); extremity numbness, pain, and/or
tingling; difficulty walking / abnormal gait; muscle spasm; and psychological problems (panic
attacks). Id. Plaintiff’s symptoms and limitations were reasonably consistent with the medical
signs and findings and Dr. Godleski stated that Plaintiff was credible regarding the severity,
durations, frequency, and other factors regarding her pain, fatigue, or other symptoms, citing
Plaintiff’s “MRI Lumbar 11/10/21 severe stenosis L4/L5[.]” R. 480. Plaintiff’s treatment
consisted of physical therapy and epidural steroid injections. Id. Dr. Godleski also indicated that
Plaintiff suffered from the following medication side effects: drowsiness, lethargy, and/or fatigue
(metaxalone and gabapentin); confusion and/or disorientation (metaxalone and gabapentin); dry
mouth (metaxalone); and blurred vision (gabapentin). Id. Asked about the expected effect of
Plaintiff’s prescribed medications on her functioning in a work setting, Dr. Godleski chose the
option “[s]ignificant side effects can be expected to limit the effectiveness of work duties, i.e.,
difficulty focusing / concentrating for frequent (34% to 66% of an 8-hour workday) periods of
time.” Id. Furthermore, her symptoms and limitations would require her to lie down or recline for
at least a total of 1.5 to 2 hours at unpredictable times of the day. R. 481. Her impairments would
likely produce “good days” and “bad days[.]” Id. Asked to identify any psychological conditions
that would affect and/or would result from Plaintiff’s physical condition, Dr. Godleski checked
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the box indicating anxiety. Id.
On apparently the same day, Dr. Godleski answered several supplemental questions. R.
482–87.6 Dr. Godleski affirmed that Plaintiff’s conditions had existed and had persisted with the
restrictions as outlined in the Medical Source Statement since at least 2016. R. 482. On average,
Plaintiff would likely need to be absent from work four or more days per month as a result of her
impairments and treatment. R. 483. Plaintiff was likely to be off task 25% of a typical workday.
R. 484. He opined on Plaintiff’s ability to do work-related activities on a day-to-day basis in a
regular work setting, using the following scale: “No limitation”; “Mild”; “Moderate” (ability to
function in this area is seriously limited and less than satisfactory, but not precluded; this is a
substantial loss of ability to perform the work-related activity; this can also mean that
functioning in this area is precluded up to one-third of the workday); “Marked” (the person
cannot satisfactorily perform this activity independently, appropriately, effectively, an on a
sustained basis in a regular work setting); “Extreme” (the person cannot perform this activity in a
regular work setting). R. 485. According to Dr. Godleski, Plaintiff had mild limitations in her
abilities to carry out very short and simple instructions; maintain attention for two hour
segments; work in coordination with or proximity to others without being unduly distracted; get
along with co-workers or peers without unduly distracting them or exhibiting behavioral
extremes; respond appropriately to changes in a routine work setting; and be aware of normal
hazards and take appropriate precautions. Id. Plaintiff was moderately limited in the following
abilities: remember work-like procedures; understand and remember very short and simple
instructions; maintain regular attendance and be punctual within customary, usually strict
6 Dr. Godleski’s answers to the supplemental questions are undated. See id. The Court Transcript
Index suggests these documents were dated October 3, 2022, the same date as his Medical
Source Statement.
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tolerances; sustain an ordinary routine without special supervision; make simple work-related
decisions; complete a normal workday and workweek without interruptions from psychologically
based symptoms; ask simple questions or request assistance; and accept instructions and respond
appropriately to criticism from supervisors. Id. Dr. Godleski also opined that Plaintiff was
markedly limited in her abilities to perform at a consistent pace without an unreasonable number
and length of rest periods and to deal with normal work stress. Id. Plaintiff’s pain “is present,
such as to prevent this patient from performing normal, full-time work activities on a frequent
(more than 3–4 days per month) basis.” R. 486. Moreover, physical activity such as walking,
standing, bending, stooping, moving or extremities, etc., would increase Plaintiff’s pain “to such
a degree as to require increased medication for pain or substantial amounts of bed rest.” Id.
According to Dr. Godleski, Plaintiff could walk 1 city block without rest or severe pain, could sit
less than 4 hours, and could stand/walk up to 1 hour in an average eight-hour working day (not
counting periods for breaks, resting, or lying down, if applicable). R. 487. Use of a cane or other
assistive device was not reasonably necessary or recommended. Id. Plaintiff could occasionally
lift and carry 10 pounds and could rarely lift and carry 20 pounds. Id.
V. DISCUSSION
A. Step Two
Plaintiff first argues that the ALJ erred in concluding, at step two of the sequential
evaluation, that Plaintiff’s anxiety was not a severe impairment. Plaintiff’s Brief, ECF No. 8, pp.
13–16; Plaintiff’s Reply Brief, ECF No. 17, pp. 3–4. For the reasons that follow, this Court
disagrees.
At step two, an ALJ determines whether the plaintiff has a “severe impairment” or
combination of impairments that “significantly limits [the plaintiff’s] physical or mental ability
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to do basic work activities[.]” 20 C.F.R. § 404.1520(c). “The step-two inquiry is a de minimis
screening device to dispose of groundless claims.” Newell v. Comm’r of Soc. Sec., 347 F.3d 541,
546 (3d Cir. 2003) (citations omitted). “So long as the ALJ rules in Plaintiff’s favor by finding
that any single impairment meets the severity threshold required at step two, any error the ALJ
made in this determination was harmless.” Auriemma v. Colvin, No. 13-5947, 2015 WL
5097902, at *6 (D.N.J. Aug. 31, 2015) (citing Salles v. Comm’r of Soc. Sec., 229 F. App’x 140,
145 n.2 (3d Cir. 2007) (“Because the ALJ found in [Plaintiff]’s favor at Step Two, even if he had
erroneously concluded that some of h[is] other impairments were non-severe, any error was
harmless.”); see also Orr v. Comm’r Soc. Sec., 805 F. App’x 85, 88 (3d Cir. 2020) (“Orr cannot
overcome that fact: because the ALJ progressed to a later step, any error at Step Two would not
alter the remainder of the five-step process, much less the overall outcome. And without more,
Orr provides no valid basis for remand.”); Rafine v. Comm’r of Soc. Sec., No. 1:19-CV-14215,
2020 WL 3073829, at *4 (D.N.J. June 10, 2020) (“The Court finds that any error in the ALJ's
step two determination as to the severity of Plaintiff's impairments of PBA, OSA, and narcolepsy
is harmless because contrary to Plaintiff's argument, the ALJ properly considered these
impairments in the overall RFC assessment.”); Edinger v. Saul, 432 F. Supp. 3d 516, 531 (E.D.
Pa. 2020) (finding that, where the ALJ found the claimant’s carpal tunnel syndrome not severe at
step two but found other impairments severe at that step and went on to consider such syndrome
when crafting the RFC at step four, “[b]ecause the ALJ properly considered Ms. Edinger’s carpal
tunnel in the remainder of the analysis, even if the ALJ erred at step two, any error was
harmless”); Hicks v. Colvin, No. 2:15-cv-07221, 2016 WL 8674251, at *8 (D.N.J. Oct. 14, 2016)
(“Even if the ALJ had in fact erred with respect to one of the impairments that she found to be
non-severe, such error would be harmless since she found other impairments to be severe,
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engaged in the full five-step evaluation, and accounted for related possible limitations in her
RFC finding.”).
As detailed above, the ALJ in this case found in Plaintiff’s favor at step two, when she
found that Plaintiff’s diabetes, cervical degenerative disc disease and radiculopathy, and lumbar
degenerative disc disease and radiculopathy were severe. R. 21. The ALJ also explained why she
found that Plaintiff had only “mild” limitations in the four broad areas of mental functioning and,
therefore, why Plaintiff’s medically determinable mental impairment of anxiety disorder was not
severe:
Mental Impairment
The claimant’s Xanax dosage on January 30, 2018 was .75 mg daily (Exhibit B4F).
Her mood and affect were normal.
Dr. McGrath examined the claimant on September 30, 2019 (Exhibit B2F). She
indicated that she felt a little depressed because she could not do anything.
The claimant requested a refill of Xanax on December 6, 2019 (Exhibit B4F). She
had last refilled the medication several months earlier and did not take it daily.
Dipal Patel, L.C.S.W., examined the claimant on November 18, 2020 (Exhibit
B4F). The claimant preferred not to take medication for her mood. She occasionally
used Xanax. She exhibited a depressed mood and affect. Her concentration was
focused. Her insight and judgment were fair. She was cooperative.
On December 11, 2020, D. Patel noted that her mental status examination remained
unchanged from November 18, 2020 (Exhibit B4F). The claimant was working on
exposure and getting more comfortable driving.
Dipal Willoughby, L.C.S.W. examined the claimant on Janaury [sic] 7, 2021
(Exhibit B4F). Her mental status examination remained unchanged from November
18, 2020. The claimant was driving short distances when the weather was nice or
with her husband in the passenger seat.
D. Willoughby noted on February 4, 2021 that her mental status examination
remained unchanged from November 18, 2020 (Exhibit B4F). The claimant
reported that she had not done much driving as she had difficulty lifting packages
if she went alone. She indicated that she resided in a remote area and there were
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few places to drive a short distance from her home. She was advised to increase her
distance away from home while driving.
On February 25, 2021, D. Willoughby examined the claimant on February 25, 2021
(Exhibit B4F). The claimant had made several trips out in the car on her own. The
claimant’s mental status examination remained unchanged from November 18,
2020 except that she had a euthymic mood and her insight and judgment were good.
D. Willoughby examined the claimant on March 24, 2021 (Exhibit B4F). The
claimant was driving more lately. She had been relaxed and took her time traveling.
She had been working to balance her needs with her mother’s needs. Her mother
resided with her and needed care, which was provided during the day. The claimant
was leaving the home during this period to attend to her needs. She was looking
into getting a part time job with Visiting Angels, which allowed her to deal with
her chronic pain and the need to get up and stretch. Her mental status examination
remained unchanged from February 25, 2021.
J. Theodore Brown, Jr., Ph.D., performed a consultative examination on April 27,
2021 (Exhibit B5F). Her medications included Xanax, which was prescribed at .25
mg by her primary care physician. She had been seeing a therapist every three
weeks for the previous two months. She complained about depressive and anxiety
related symptoms. Her hygiene was adequate. She had acquaintances, not friends.
She shared household chores with her husband. Her husband managed the financial
matters. She could manage her personal care needs. She spent her time at home on
the couch watching television, napping, pacing herself and navigating her pain.
Upon examination, the claimant had normal motor behavior and normal eye
contact. Her mood was neutral. Her affect was appropriate. Her judgment was intact
and her insight was fair. She had an impaired memory. She could perform simple
calculations. Her concentration was impaired. The claimant was diagnosed with
major depressive disorder, generalized anxiety disorder and rule out PTSD.
Lynette Albanese, L.P.C., examined the claimant on June 28, 2021 (Exhibit B6F).
The claimant had been in a motor vehicle accident in 2016 and was afraid to drive.
Her primary care physician had recommended that she attend therapy to manage
her anxiety. She was frustrated by being in pain all of the time. She felt
overwhelmed, angry and frustrated. She was unable to focus due to her anxiety. She
ended her relationship with her previous therapist in April 2021 after she attended
6 sessions but had a disagreement about their expectations of therapy. Upon
examination, her mood was angry and her affect was appropriate. She had no
deficits in her memory, attention or concentration. Her insight and judgment were
intact. The remainder of her mental status examination was normal. She was
diagnosed with generalized anxiety disorder.
Date Last Insured – December 31, 2021
15
Gianna Vaccarino, L.P.C., examined the claimant on December 13, 2022 (Exhibit
B12F). She underwent a total of six treatment sessions prior to the end of her
treatment on March 1, 2023. On January 18, 2023, the claimant indicated that she
had recently taken a solo drive of approximately 30 minutes in length. The claimant
admitted to taking a few short distance drives during the week prior to February 1,
2023. By March 1, 2023, the claimant reported that she had symptoms related to
the interview process for a job, her relationship with her husband and driving
anxiety. She took her usual weekend drives with her husband and felt moderate
anxiety. During her mental status examination, her memory, attention and
concentration were intact. Her insight and judgment were intact. Her thought
process was tangential and her affect was anxious and sad. Her presentations
between December 13, 2022 and February 15, 2023 were generally consistent with
her presentation on March 1, 2023 as they reflected anxiety in her affect with other
factors on occasion. She was diagnosed with phobic anxiety disorder and
generalized anxiety disorder.
On March 31, 2023, Gianna Vaccarino, L.P.C., indicated that the claimant had been
treated since December 12, 2022 for anxiety disorder and fear of driving or being a
passenger in a car (Exhibit B14F).
The claimant’s medically determinable mental impairment of anxiety disorder did
not cause more than minimal limitation in the claimant’s ability to perform basic
mental work activities and was therefore nonsevere.
In making this finding, the undersigned has considered the broad functional areas
of mental functioning set out in the disability regulations for evaluating mental
disorders and in the Listing of Impairments (20 CFR, Part 404, Subpart P, Appendix
1). These four broad functional areas are known as the “paragraph B” criteria.
The first functional area is understanding, remembering or applying information.
In this area, the claimant had mild limitation.
On November 11, 2020, the claimant completed an Adult Function Report (Exhibit
B5E). She needs reminders to take her medications and manage her personal care
needs. She can manage her financial matters. She has problems with understanding,
memory and following instructions.
The claimant completed an Adult Function Report on July 6, 2021 (Exhibit B8E).
She needs reminders to take her medications and manage her personal care needs.
She can manage her financial matters. She has problems with understanding,
memory and following instructions.
The undersigned notes that the claimant alleged problems with understanding,
remembering and applying information (Exhibits B5E and B8E). The undersigned
notes that the claimant’s memory, was impaired and her insight and judgment were
fair during Dr. Brown’s examination (Exhibit B5F). However, he was a one-time
16
examining mental health professional, who was not in a treatment relationship with
the claimant and could not provide care. Approximately nine weeks later, during
an evaluation with a treating medical professional, who could provide care, she had
no memory deficits and intact insight and judgment (Exhibit B6F). Further, even
though her evaluations with Ms. Vaccarino were after the date last insured, she
continued to exhibit an intact memory and intact insight and judgment between
December 2022 and February 2023 (Exhibit B12F). She could manage her financial
matters (Exhibits B5E and B8E). After carefully considering these factors including
one episode of fair insight and judgment in 2020, the undersigned finds that she has
a mild limitation in this broad area of mental functioning (Exhibit B4F).
The next functional area is interacting with others. In this area, the claimant had
mild limitation.
On November 11, 2020, the claimant completed an Adult Function Report (Exhibit
B5E). She shops in stores. She spends time with others. She socially isolates. She
has problems getting along with others because she has no time for disloyalty. She
can get along with authority figures. She has never been fired from a job due to
problems getting along with others.
The claimant completed an Adult Function Report on July 6, 2021 (Exhibit B8E).
She shops in stores. She spends time with others. She socially isolates. She has
problems getting along with others because she has no time for disloyalty. She can
get along with authority figures. She has never been fired from a job due to
problems getting along with others.
The undesigned notes that the claimant alleged that she socially isolated herself and
had problems getting along with others (Exhibits B5E and B8E). She had few
friends but her self-reports reflect no issues with getting along with authority
figures or co-workers. As a result, the undersigned finds that she has a mild
limitation in this broad area of mental functioning.
The third functional area is concentrating, persisting or maintaining pace. In this
area, the claimant had mild limitation.
On November 11, 2020, the claimant completed an Adult Function Report (Exhibit
B5E). She has problems with paying attention and concentration.
The claimant completed an Adult Function Report on July 6, 2021 (Exhibit B8E).
She has problems with paying attention and concentration.
The undersigned notes that the claimant alleged problems with concentration and
paying attention (Exhibits B5E and B8E). The undersigned notes that the claimant
does not carry a diagnosis of attention deficit disorder and there is no indication
that she is taking stimulant medication to manage her symptoms. The undersigned
notes that the claimant’s concentration was impaired during Dr. Brown’s
17
examination (Exhibit B5F). However, he was a one-time examining mental health
professional, who was not in a treatment relationship with the claimant and could
not provide care. Approximately nine weeks later, during an evaluation with a
treating medical professional, who could provide care, the claimant had intact
concentration and attention (Exhibit B6F). Further, even though her evaluations
with Ms. Vaccarino were after the date last insured, she continued to exhibit intact
concentration and attention between December 2022 and February 2023 (Exhibit
B12F). Her concentration was focused in November 2020 (Exhibit B4F). As a
result, the undersigned finds that she has a mild limitation in this broad area of
mental functioning.
The fourth functional area is adapting or managing oneself. In this area, the
claimant had mild limitation.
On November 11, 2020, the claimant completed an Adult Function Report (Exhibit
B5E). She has problems with stress and changes.
The claimant completed an Adult Function Report on July 6, 2021 (Exhibit B8E).
She has problems with stress and changes.
The undersigned notes that the claimant alleged problems with stress and changes
in routine (Exhibits B5E and B8E). The undersigned notes that there is no evidence
that the claimant has appeared to be unkempt, malodorous or disheveled during the
period at issue (Exhibit B5F). She can manage her safety needs and is careful about
her driving (Exhibit B4F). She could manage her emotional state in public. The
undersigned considered her allegations of problems with stress and changes in
routine in assigning a mild limitation in this area of mental functioning.
Because the claimant’s medically determinable mental impairment caused no more
than “mild” limitation in any of the functional areas and the evidence does not
otherwise indicate that there is more than a minimal limitation in the claimant’s
ability to do basic work activities, it was nonsevere (20 CFR 404.1520a(d)(1)).
The limitations identified in the “paragraph B” criteria are not a residual
functional capacity assessment but are used to rate the severity of mental
impairments at steps 2 and 3 of the sequential evaluation process. The mental
residual functional capacity assessment used at steps 4 and 5 of the sequential
evaluation process requires a more detailed assessment. The following residual
functional capacity assessment reflects the degree of limitation the undersigned has
found in the “paragraph B” mental function analysis.
The State agency psychological consultants concluded that the claimant had a mild
limitation in her ability to understand, remember or apply information, interact with
others, concentrate, persist or maintain pace and adapt or manage herself (Exhibits
B2A and B3A).
18
The undersigned finds that the opinions of the State agency psychological
consultants are persuasive (Exhibits B2A and B3A). They are supported by the
evaluations of the psychological consultants at the time they formed their opinions
and they are consistent with other medical evidence of record for the reasons noted
above.
R. 24–28 (emphasis added). The Court finds no error with the ALJ’s findings in this regard. See
20 C.F.R. § 404.1520a(d)(1) (providing that an ALJ may conclude that a mental health
impairment is non-severe if a claimant’s mental health impairment causes only mild limitation in
all four B criteria); cf. Rolick v. Berryhill, No. CV 17-4481, 2019 WL 625599, at *5 (D.N.J. Feb.
14, 2019) (finding that while the claimant “does have mental health conditions that undoubtedly
produced symptoms, the ALJ had a more than adequate basis for concluding that those mental
health conditions were not severe as that term is used within the Act” where the claimant’s
“mental health examinations demonstrated adequate mental functioning with intact thought
processes, memory span, and concentration” and “[i]t would be inappropriate for this Court to
substitute its own judgment in weighing the mental health evidence because the ALJ properly
relied on substantial evidence in her determination that [the claimant’s] mental health
impairments were non-severe and caused only mild limitations”).
Plaintiff nevertheless points to evidence that she believes establishes that her anxiety is
severe. Plaintiff’s Brief, ECF No. 8, pp. 15–16; Plaintiff’s Reply Brief, ECF No. 17, pp. 3–4.
Plaintiff points to medical diagnoses of depression and anxiety. Plaintiff’s Brief, ECF No. 8, pp.
15–16. However, “[a] diagnosis alone . . . does not demonstrate disability.” Foley v. Comm’r of
Soc. Sec., 349 F. App’x 805, 808 (3d Cir. 2009) (citing Petition of Sullivan, 904 F.2d 826, 845
(3d Cir. 1990)); see also Phillips v. Barnhart, 91 F. App’x 775, 780 (3d Cir. 2004) (“[The
claimant’s] argument incorrectly focuses on the diagnosis of an impairment rather than the
functional limitations that result from that impairment. A diagnosis of impairment, by itself, does
19
not establish entitlement to benefits under the Act”). Plaintiff also observes that her “treating
pain management physician has noted the Plaintiff’s depression is directly related to her physical
impairments. (AR 347).” Plaintiff’s Brief, ECF No. 8, pp. 15 (citing R. 347 (“The patient is
suffering from depression. PT STATED SHE FEELS A LITTLE DEPRESSED BECAUSE SHE
CAN'T DO ANYTHING.”) (emphasis in the original)), 16 (citing R. 421–22). This reliance is
unavailing: A physician’s memorialization of a patient’s subjective complaints in a medical
record does not transform those complaints into objective findings or a medical opinion. Hatton
v. Comm’r of Soc. Sec. Admin., 131 F. App’x 877, 879 (3d Cir. 2005) (“[A] medical source does
not transform the claimant’s subjective complaints into objective findings simply by recording
them in his narrative report[.]”) (summarizing Craig v. Chater, 76 F.3d 585, 590 n. 2 (4th Cir.
1996)); Morris v. Barnhart, 78 F. App’x 820, 824–25 (3d Cir. 2003) (“[T]he mere
memorialization of a claimant’s subjective statements in a medical report does not elevate those
statements to a medical opinion.”) (citations omitted). Moreover, the ALJ expressly considered
this evidence at step two, R. 24 (“Dr. McGrath examined the claimant on September 30, 2019
(Exhibit B2F). She indicated that she felt a little depressed because she could not do anything.”),
and the Court will not reweigh this evidence. See Chandler v. Comm’r of Soc. Sec., 667 F.3d
356, 359 (3d Cir. 2011) (“Courts are not permitted to reweigh the evidence or impose their own
factual determinations [under the substantial evidence standard].”); Hatton, 131 F. App’x at 880
(“When ‘presented with the not uncommon situation of conflicting medical evidence . . . [t]he
trier of fact has the duty to resolve that conflict.’”) (quoting Richardson v. Perales, 402 U.S. 389,
399 (1971)). To the extent that Plaintiff relies on her own subjective complaints, Plaintiff’s Brief,
ECF No. 8, pp. 15–16; Plaintiff’s Reply Brief, ECF No. 17, pp. 3–4, the ALJ specifically
explained later in the decision why the ALJ discounted those complaints, R. 30, 33–34, a
20
determination that Plaintiff does not apparently challenge. Plaintiff also points to a consultative
examination. Plaintiff’s Brief, ECF No. 8, p. 16 (citing R. 419–22).7 However, the ALJ expressly
considered this evidence when determining that Plaintiff had no more than mild limitations in all
four of the broad areas of functioning under paragraph B of the listings. R. 25–27. The Court
again declines Plaintiff’s invitation to reweigh this evidence. See Chandler, 667 F.3d at 359;
Hatton, 131 F. App’x at 880
Moreover, even if the ALJ erred in concluding, at step two, that Plaintiff’s anxiety was
not a severe impairment, any such error was harmless because the ALJ also found that other
impairments were severe, R. 21, and the ALJ continued to evaluate Plaintiff’s impairments
through the remainder of the five-step sequential evaluation. R. 28–37. Accordingly, Plaintiff
has not shown that the ALJ committed reversible error at step two when assessing Plaintiff’s
mental health impairment. See Salles, 229 F. App’x at 145 (“Because the ALJ found in Salles’s
favor at Step Two, even if he had erroneously concluded that some of her other impairments
were non-severe, any error was harmless.”) (citations omitted).
7 J. Theodore Brown Jr., Ph.D., H.S.P.P., conducted a consultative examination on April 27,
2021, and concluded after that examination:
DIAGNOSTIC IMPRESSION:
Major Depression Disorder.
Generalized Anxiety Disorder.
Rule Out Post-Traumatic Stress Disorder.
PROGNOSIS: Undetermined, very much dependent upon Claimant receiving
appropriate mental healthcare support and treatment and benefiting from the same
and receiving appropriate medical care and relief from physical pain and suffering.
ABILITY TO MANAGE HER OWN FUNDS: It is recommended that Claimant
be better stabilized physically and mentally before being allowed to assume
responsibility for managing her financial affairs.
R. 422.
21
B. RFC and Opinion Evidence
Plaintiff argues that the ALJ’s RFC is flawed because the ALJ failed to include
limitations to accommodate Plaintiff’s mild mental limitations and failed to include Dr.
Godleski’s opined mental limitations. Plaintiff’s Brief, ECF No. 8, pp. 16–22; Plaintiff’s Reply
Brief, ECF No. 17, pp. 1–3. The Court disagrees.
At step four of the sequential evaluation process, the ALJ found that Plaintiff had the
RFC to perform sedentary work “except she can occasionally climb ramps or stairs, stoop, kneel,
or crouch but never climb a ladder, rope or scaffold or crawl. No exposure to hazards, such as
machinery, heights or motor vehicles.” R. 29. In making this determination, the ALJ considered,
inter alia, Plaintiff’s hearing testimony that, among other things, she “experiences brain fog
when she is anxious. At the grocery store, she will write a list and then forget things.” R. 30. The
ALJ also considered Plaintiff subjective complaints and explained why the record “does not
document sufficient objective medical evidence to substantiate the severity of the pain and
degree of functional limitations alleged by the claimant.” R. 33; see also R. 30, 34. The ALJ
went on to consider, inter alia, the opinions of Dr. Godleski as follows:
Thomas Godleski, D.O., concluded on October 3, 2022 that the claimant had side
effects from her medication (Exhibit B9F). Her side effects could be expected to
limit the effectiveness of her work duties and she would frequently experience
problems with focus and concentration. She would need to lie down or recline for
a total of up to 2 hours during the day on a daily basis. She would be absent more
than 4 days per month and off task 25 percent or more of the work day. Pain
impacted her functioning. She could walk 1 block without resting or severe pain.
She could sit less than 4 hours in an 8 hour work day, stand or walk up to 1 hour in
an 8 hour work day. she could occasionally lift 10 pounds or less and rarely lift 20
pounds.
Dr. Godleski concluded on October 3, 2022 that the claimant had a mild to
moderate limitation in all areas aside from performing at a consistent pace without
an unreasonable number and length of rest periods or dealing with normal work
stress, which were both marked in their level of limitation (Exhibit B9F).
22
Dr. Godleski approved a handicap placard for the claimant’s car on March 23, 2023
(Exhibit B13F). He concluded that she was severely and permanently limited in her
ability to walk due to an arthritic, neurological or orthopedic condition or she could
not walk 200 feet without stopping to rest.
The undersigned notes that all of Dr. Godleski’s opinions were formed after the
date last insured (Exhibit B9F and B13F). The undersigned notes that he has not
submitted his treatment notes for this time period or any period of time after
September 21, 2020, the only examination treatment note submitted by Dr.
Godleski (Exhibit B4F). In his September 21, 2020 examination findings, he noted
no functional deficits in any area during his physical examination. As a result, his
opinions are not supported by his examination treatment notes. In addition, they are
not consistent with other medical evidence of record for the reasons noted above.
R. 35–36.
An ALJ must evaluate all record evidence in making a disability determination. Plummer,
186 F.3d at 433; Cotter, 642 F.2d at 704. The ALJ’s decision must include “a clear and
satisfactory explication of the basis on which it rests” sufficient to enable a reviewing court “to
perform its statutory function of judicial review.” Cotter, 642 F.2d at 704–05. Specifically, the
ALJ must discuss the evidence that supports the decision, the evidence that the ALJ rejected, and
explain why the ALJ accepted some evidence but rejected other evidence. Id. at 705–06; Diaz v.
Comm’r of Soc. Sec., 577 F.3d 500, 505–06 (3d Cir. 2009); Fargnoli v. Massanari, 247 F.3d 34,
42 (3d Cir. 2001) (“Although we do not expect the ALJ to make reference to every relevant
treatment note in a case . . . we do expect the ALJ, as the factfinder, to consider and evaluate the
medical evidence in the record consistent with his responsibilities under the regulations and case
law.”). Without this explanation, “the reviewing court cannot tell if significant probative
evidence was not credited or simply ignored.” Cotter, 642 F.2d at 705; see also Burnett, 220
F.3d at 121 (citing Cotter, 642 F.2d at 705).
23
For claims filed after March 27, 2017,8 the Commissioner’s regulations eliminated the
hierarchy of medical source opinions that gave preference to treating sources. Compare 20
C.F.R. § 404.1527 with 20 C.F.R. § 404.1520c(a) (providing, inter alia, that the Commissioner
will no longer “defer or give any specific evidentiary weight, including controlling weight, to
any medical opinion(s) or prior administrative medical finding(s), including those from [the
claimant’s] medical sources”). Instead, the Commissioner will consider the following factors
when considering all medical opinions: (1) supportability; (2) consistency; (3) relationship with
the claimant, including the length of the treating examination, the frequency of examinations,
and the purpose of the treatment relationship; (4) the medical source’s specialization; and (5)
other factors, including, but not limited to, “evidence showing a medical source has familiarity
with the other evidence in the claim or an understanding of our disability program’s policies and
evidentiary requirements.” 20 C.F.R. § 404.1520c(c).
The applicable regulation emphasizes that “the most important factors [that the ALJ and
Commissioner] consider when [] evaluat[ing] the persuasiveness of medical opinions and prior
administrative medical findings are supportability (paragraph (c)(1) of this section) and
consistency (paragraph (c)(2) of this section).” Id. at § 404.1520c(a). As to the supportability
factor, the regulation provides 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). As to the
consistency factor, the regulation provides that “[t]he more consistent a medical opinion(s) or
prior administrative medical finding(s) is with the evidence from other medical sources and
8 As previously noted, Plaintiff’s claim was filed on April 20, 2021.
24
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).
The applicable regulation further requires the ALJ to articulate her “consideration of
medical opinions and prior administrative medical findings” and articulate in the “determination
or decision how persuasive [she] find[s] all of the medical opinions and all of the prior
administrative medical findings in [the claimant’s] case record.” Id. at § 404.1520c(b). As
previously noted, “[s]upportability and consistency are the most important factors. . . . ALJs need
not explain their determinations regarding the other factors, but they must discuss supportability
and consistency.” Gongon v. Kijakazi, 676 F. Supp. 3d 383, 394 (E.D. Pa. 2023) (citations
omitted); see also Stamm v. Kijakazi, 577 F. Supp. 3d 358, 370 (M.D. Pa. 2021) (“Generally, the
ALJ may, but is not required to, explain his or her consideration of the other factors, but if there
are two equally persuasive medical opinions about the same issue that are not exactly the same,
then the ALJ must explain how he or she considered the other factors.”). Finally, an ALJ “need
not reiterate the magic words ‘support’ and ‘consistent’ for each doctor” in order to satisfy the
articulation requirements for the supportability and consistency factors, providing that the judge
“weave[s] supportability and consistency throughout her analysis of which doctors were
persuasive.” Zaborowski v. Comm’r of Soc. Sec., 115 F.4th 637, 639 (3d Cir. 2024).
Plaintiff argues that the ALJ improperly failed to consider Plaintiff’s mental impairment
— even if it was non-severe—when crafting the RFC. Plaintiff’s Brief, ECF No. 8, pp. 16–19;
Plaintiff’s Reply Brief, ECF No. 17, pp. 1–3. Plaintiff specifically contends that the RFC makes
no mention of any mental limitations despite the fact that the ALJ found limitations in each of
the four areas of mental functioning under paragraph B. Id.
25
To the extent that Plaintiff suggests that the ALJ’s finding at step two—i.e., that
Plaintiff’s non-severe mental impairment of anxiety caused mild mental limitations—requires a
particular discussion at step four, “no incantations are required at steps four and five simply
because a particular finding has been made at steps two and three. Those portions of the
disability analysis serve distinct purposes and may be expressed in different ways”; therefore,
“the findings at steps two and three will not necessarily translate to the language used at steps
four and five.” Hess v. Comm’r Soc. Sec., 931 F.3d 198, 209 (3d Cir. 2019). Moreover, “[w]hat
matters instead is whether the ALJ properly accounted for any mental impairments in
formulating the Plaintiff’s RFC.” Brodman v. Bisignano, No. 3:24:CV-0139, 2025 WL 1993610,
at *5–6 (W.D. Pa. July 17, 2025) (finding that the ALJ did properly account for such
impairments when, “[a]lthough the ALJ concluded at step two—with references to the record—
that Plaintiff’s mental impairments were not severe, the ALJ nevertheless went on to consider, at
step four of the sequential evaluation process, her anxiety and depressive symptoms as well as
any alleged limitations flowing from them, explaining why those mild mental impairments
warranted no functional limitations in the RFC). Here, at step two, the ALJ explained why she
concluded that Plaintiff had only mild limitations in the four broad areas of mental functioning
under paragraph B, R. 24–28, and expressly stated that she considered the paragraph B
limitations when crafting the RFC. R. 28 (“The following residual functional capacity
assessment reflects the degree of limitation the undersigned has found in the ‘paragraph B’
mental function analysis.”). Then, at step four, the ALJ expressly stated that she had “considered
all symptoms and the extent to which these symptoms can reasonably be accepted as consistent
with the objective medical evidence and other evidence[,]” R. 29, and acknowledged that, in
crafting the RFC, she must consider mental limitations and the ability to perform mental tasks. R.
26
32–33. The ALJ also specifically considered Plaintiff’s allegations of “brain fog” and
forgetfulness relating to her anxiety. R. 30. However, as previously noted, the ALJ explained
why substantial evidence did not support the degree of functional limitation alleged by Plaintiff.
R. 30, 33–34. Moreover, as noted above and as discussed in more detail below, the ALJ further
considered Plaintiff’s alleged limitations flowing from her non-severe mental impairment when
she explained why she discounted Dr. Godleski’s opinion. R. 35–36. Considering this record as a
whole, the Court is not persuaded that the ALJ erred when she did not include any functional
limitations in the RFC purportedly flowing from Plaintiff’s mild mental limitations. R. 24–36;
see also Williams v. Bisignano, No. 2:24-CV-1747, 2026 WL 312471, at *1 (W.D. Pa. Jan. 5,
2026) (finding that, “[c]ontrary to Plaintiff's argument, these non-severe impairments and
Paragraph B Criteria findings did not require specific limitations in Plaintiff’s RFC” where “the
ALJ examined the source opinions relating to Plaintiff's mental limitations and found them
unpersuasive because they were inconsistent with the medical records” and “found Plaintiff’s
allegations not fully supported by the objective evidence” and therefore concluding that
“[a]ltogether, the record shows that the ALJ provided a sufficient explanation for the crafted
RFC finding containing no limitations for Plaintiff’s non-severe mental impairments”);
Brodman, 2025 WL 1993610, at *6 (W.D. Pa. July 17, 2025) (finding that the ALJ sufficiently
considered the claimant’s mild mental limitations when considering and discounting a
consultative opinion and noting that records revealed an unremarkable mental status and
concluding that the ALJ’s “thorough analysis evidences the ALJ’s reliance on sufficient evidence
of record to support her conclusion that the Plaintiff was not disabled); Jennifer J. v. Bisignano,
No. CV 24-1863, 2025 WL 1435628, at *6–7 (E.D. Pa. May 19, 2025) (finding that Plaintiff
“has not shown that the ALJ failed to properly capture all of her limitations, including limitations
27
resulting from her mild mental impairments in reaching his determination that she retained the
ability to perform the duties of her past relevant work as a bookkeeper” where the ALJ explained
that he considered all of Plaintiff’s medically determinable impairments, including non-severe
impairments; her symptoms to the extent they could be reasonably accepted as consistent with
the objective medical evidence; prior administrative medical findings; record evidence that
Plaintiff was “usually cooperative calm, polite, friendly, and sociable” and that exam findings
“consistently show[ed]” that she was “fully oriented and alert with intact cognition, ability to
obey commands, and normal memory, attention and concentration” and “mental status exams
showing [that she] was generally alert, oriented, and cooperative with no psychosis, no ongoing
suicidal/homicidal ideation, and normal memory, attention, and concentration”); cf. Makowski v.
Comm’r of Soc. Sec., No. CV 16-1656 (JBS), 2017 WL 3151243, at *6–7 (D.N.J. July 24, 2017)
(“Plaintiff has not offered any support for her position that someone with a mild limitation in
three broad functional areas . . . is incapable of performing a job rated with a skill level of six, as
her past relevant work as a bookkeeper is. . . . Because the ALJ need only include credible
limitations in the RFC, and because there is substantial evidence supporting the ALJ’s
conclusion that Plaintiff’s mental impairments would cause only mild limitations on her daily
life and not impact her work, the Court will not remand on this basis.”).
Although Plaintiff complains that the ALJ failed to accommodate in the RFC Plaintiff’s
“discernable limitations, consistent with the Plaintiff’s testimony regarding her memory lapses,
fatigue, or anxiety”, she does not identify in functional terms what those limitations are.
Plaintiff’s Brief, ECF No. 8, pp. 18–19; Plaintiff’s Reply Brief, ECF No. 18, pp. 2–4. Plaintiff’s
observation that a treating physician “noted the Plaintiff’s depression is directly related to her
physical impairments,” Plaintiff’s Reply Brief, ECF No. 17, p. 2 (citing R. 347), and her
28
reference to the findings of the consultative examiner, Dr. Brown, Plaintiff’s Reply Brief, ECF
No. 17, pp. 2–3; R. 419–22, are similarly unavailing because those sources failed to articulate
any functional limitations.
To the extent that Plaintiff points to a portion of the vocational expert’s testimony, based
on a hypothetical RFC that was different from that ultimately found by the ALJ, i.e., one that
includes a limitation to simple tasks, Plaintiff’s Brief, ECF No. 8, p. 18 (citing R. 60), the ALJ
did not err in omitting that unsupported limitation. See Podedworny, 745 F.2d at 218 (stating
that a “vocational expert’s testimony concerning a claimant’s ability to perform alternative
employment may only be considered for purposes of determining disability if the question
accurately portrays the claimant’s individual physical and mental impairments”); Chrupcala v.
Heckler, 829 F.2d 1269, 1276 (3d Cir. 1987) (“A hypothetical question must reflect all of a
claimant’s impairments that are supported by the record; otherwise the question is deficient and
the expert’s answer to it cannot be considered substantial evidence.”); Peterman v. Berryhill, No.
CV 18-13751, 2019 WL 2315016, at *8–10 (D.N.J. May 31, 2019), appeal dismissed (Dec. 19,
2019) (“[T]here was ample evidence in the record indicating that Plaintiff’s mild mental
impairments did not meaningfully impact her ability to function during the relevant period. . . .
Thus, the ALJ’s decision to exclude Plaintiff’s mild mental impairments from the RFC was
supported by substantial evidence, nor did the ALJ err by failing to include Plaintiff’s mild
mental limitations in her hypothetical question to the VE.”); O’Neill v. Comm’r of Soc. Sec., No.
CV 18-0698 (RBK/KMW), 2019 WL 413539, at *9 (D.N.J. Jan. 31, 2019) (“[T]he ALJ does not
have a duty to respond to Plaintiff’s counsel’s attempts to expand the hypothetical question.
Again, SSR-004P only focuses on apparent conflicts with the VE’s testimony and the DOT
29
listing, not attempted conflicts with the initial ALJ hypothetical and a newly revised one from
Plaintiff’s counsel”).
Plaintiff next complains that the ALJ erred in discounting Dr. Godleski’s opinions,
asserting that, “as a practical matter, the ALJ’s basis for rejecting the medical evidence due to a
lack of medical evidence from that provider is factually incorrect.” Plaintiff’s Brief, ECF No. 8,
pp. 19–22; see also Plaintiff’s Reply Brief, ECF No. 18, p. 3. Noting that his medical opinion is
dated October 3, 2022 (i.e., after the date last insured of December 31, 2021), the doctor stated
that he had treated Plaintiff for more than eleven years. Plaintiff’s Brief, ECF No. 8, p. 20.
According to Plaintiff, Dr. Godleski’s “notes are dispersed throughout the medical record and are
part of a medical facility in which she sees multiple different providers, including Dipal
Willoughby, Dr. Pradeep Patel (opthamology [sic]), Dr. Murray Buck and Dr. Shika
Chowdhury.” Id. (citing R. 363–418). Therefore, Plaintiff argues, “[t]he ALJ’s determination
that this medical opinion is not persuasive because his name is not on each medical record, is, at
best, a disingenuous statement” and that the ALJ was not free to ignore contrary evidence. Id. at
20–21. Had the ALJ properly considered Dr. Godleski’s opinion, Plaintiff argues, the outcome
would have been “markedly different” because the ALJ would have concluded that Plaintiff
could not perform her past semi-skilled and skilled work. Id. at 22.
Plaintiff’s arguments are not well taken. As detailed above, the ALJ properly noted that
the single treatment note from Dr. Godleski, from September 2021, did not support his extreme
opinion. R. 35–36. Plaintiff has not persuaded this Court that the ALJ erred in oncluding that this
physician’s opinion was not supported by his own treatment notes. Id.; see also 20 C.F.R. §
404.1520c(c)(1); Pipkin v. Kijakazi, No. CV 22-2-E, 2023 WL 411291, at *1 (W.D. Pa. Jan. 25,
2023) (“‘[S]upportability relates to the extent to which a medical source has articulated support
30
for the medical source’s own opinion[.]’”) (quoting Cook v. Comm’r of Soc. Sec., No. 6:20-CV-
1197, 2021 WL 1565832, at *3 (M.D. Fla. Apr. 6, 2021)); Tyler E. K. v. Comm’r of Soc. Sec.,
No. 21-9623, 2022 WL 3913559, at *6 (D.N.J. Aug. 31, 2022) (finding that the ALJ
appropriately considered the supportability and consistency factors by citing the physician’s
treatment notes and other evidence in the record). The ALJ next explained that Dr. Godleski’s
opinion was “not consistent with other medical evidence of record for the reasons noted above.”
R. 36. That other evidence included, inter alia, Plaintiff’s subjective complaints, which the ALJ
discounted, and, with one exception, evidence that Plaintiff had no memory deficits and had
intact insight and judgment; evidence that she had no issues getting along with authority figures
and had never been fired from a job because of problems getting along with others; no evidence
that Plaintiff appeared unkempt or disheveled during the relevant period; and evidence that
Plaintiff was able to drive and could manage her emotional state in public. R. 24–28, 30, 33.
Based on this record, the ALJ properly found that Dr. Godleski’s extreme opined mental
limitations were not consistent with the record. See id.; see also 20 C.F.R. § 404.1520c(c)(2);
Celento v. Comm’r Soc. Sec., 613 F. App’x 205, 206–07 (3d Cir. 2015) (noting that daily
activities such as, inter alia, driving “require at least some . . . mental concentration”); Serrano v.
Kijakazi, No. CV 20-3985, 2021 WL 4477137, at *3–4 (E.D. Pa. Sept. 30, 2021) (“In this case,
the ALJ discussed and analyzed the evidence extensively before determining the persuasiveness
of the medical opinions. . . . The ALJ was not required to repeat this information for the sake of
elaborating on her findings of persuasiveness.”).
In short, for all these reasons, the Court concludes that the ALJ’s findings regarding
Plaintiff’s RFC enjoy substantial support in the record, as does her consideration of Dr.
Godleski’s opinion.
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VI. CONCLUSION
For these reasons, the Court AFFIRMS the Commissioner’s decision.
The Court will issue a separate Order issuing final judgment pursuant to Sentence 4 of 42
U.S.C. § 405(g).
IT IS SO ORDERED.
Date: April 14, 2026 s/Norah McCann King
NORAH McCANN KING
UNITED STATES MAGISTRATE JUDGE
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