Opinions and documents
UNITED STATES DISTRICT COURT
DISTRICT OF NEW JERSEY
PAUL W.,1
Plaintiff, Case No. 3:24-cv-8712
Magistrate Judge Cheryl L. Pollak
v.
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 Paul W. 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 Plaintiff’s
application.2 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 reverses the Commissioner’s decision and
remands the matter for further proceedings.
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 Commissioner of Social Security, is substituted as Defendant in his
official capacity.
1
I. PROCEDURAL HISTORY
On July 29, 2022, Plaintiff filed an application for disability insurance benefits, alleging
that he had been disabled since an alleged onset date of November 1, 2019. R. 80–81, 166–70.
Plaintiff’s application was denied initially and upon reconsideration. R. 74-91, 98-100. Plaintiff
sought a de novo hearing before an administrative law judge (“ALJ”). R. 101–02. ALJ Elana
Hollo held a telephonic hearing on September 7, 2023, at which Plaintiff, who was represented
by counsel Glenn B. Carey, testified, as did an impartial vocational expert, Tanja Hubacker. R.
40-73.
In a decision dated January 10, 2024, the ALJ concluded that Plaintiff was not disabled
within the meaning of the Social Security Act from November 1, 2019, the alleged onset date,
through June 30, 2022, the last date insured. R. 24-35. That decision became the final decision of
the Commissioner of Social Security when the Appeals Council declined review on June 20,
2024. R. 1–6. Plaintiff timely filed this appeal pursuant to 42 U.S.C. § 405(g). ECF No. 1. On
May 21, 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. 7.3 On April 20, 2026, the case was reassigned to the undersigned. ECF No. 22. The matter is
now 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
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
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) & 1383(c)(3). The United States Supreme Court has
explained this standard as follows:
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)).
3
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,
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 the 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
4
(“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
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). A decision to “award
benefits should be made only when the administrative record of the case has been fully
developed and when substantial evidence on the record as a whole indicates that the claimant is
disabled and entitled to benefits.” Podedworny, 745 F.2d at 221-22 (citation and quotation
5
omitted); see A.B., 166 F. Supp.3d at 518. In assessing whether the record is fully developed to
support an award of benefits, courts take a more liberal approach when the claimant has already
faced long processing delays. See, e.g., Morales v. Apfel, 225 F.3d 310, 320 (3d Cir. 2000). An
award is “especially appropriate when “further administrative proceedings would simply prolong
[Plaintiff’s] waiting and delay his ultimate receipt of benefits.” Podedworny, 745 F.2d at 223;
see Schonewolf, 972 F. Supp. at 290.
B. Sequential Evaluation Process
The Social Security Act establishes a five-step sequential evaluation 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)).
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. §
6
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
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
Plaintiff was 47 years old on the date last insured. R. 33. The ALJ found that Plaintiff
met the insured status requirements of the Social Security Act through June 30, 2022. R. 26. At
step one, the ALJ found that the Plaintiff had not engaged in substantial gainful activity between
November 1, 2019, his alleged onset date, and the date last insured of June 30, 2022. Id.
At step two, the ALJ found that Plaintiff suffered from the following severe impairments:
degenerative disc disease of the thoracic and lumbar spine depression, generalized anxiety
disorder, schizophrenia spectrum disorder and adjustment disorder. Id. The ALJ also found that
the following medically determinable impairments were not severe: left shoulder impairment,
cervical spine impairment, and testicular pain R. 26-27.
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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. 27-29.
At step four, the ALJ found that Plaintiff had the RFC to perform light work subject to
various exertional and non-exertional limitations. R. 29–33. The ALJ also found that the Plaintiff
was unable to perform his past relevant work as a traffic controller, but that he was able to make
“a successful adjustment to other work that existed in significant numbers in the national
economy,” citing the testimony of the vocational expert who identified the following
representative occupations: “marker” (30,000 positions nationally); routing clerk (50,000
positions nationally); and cleaner (100,000 positions nationally). R. 34–35.
Plaintiff disagrees with the ALJ’s findings at step four and asks that the decision of the
Commissioner be reversed and remanded for further proceedings. Plaintiff’s Brief, ECF No. 14
(“Pl. Br.”); Plaintiff’s Reply Brief, ECF No. 21 (“Pl. Reply”). Specifically, Plaintiff contends that
the ALJ formulated the RFC without adequate medical opinion evidence, ignoring the initial
disability determination that found insufficient evidence to determine the extent of Plaintiff’s
physical and mental impairments, and substituting her own lay interpretation of the medical
evidence. Pl. Br. at 8-13. 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. 20 (“D. Br.”).
IV. SUMMARY OF RELEVANT MEDICAL EVIDENCE
In determining whether Plaintiff was disabled and the extent of limitations caused by his
impairments, the ALJ first reviewed Plaintiff’s testimony at the hearing, in which he stated that
he stopped working as an independent handyman in 2019 “due to the cumulative effects of back
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pain and [he] was unable to stand or walk.” R. 29. The ALJ noted that Plaintiff testified that he
attended physical therapy in 2022 for low back pain, and that he became depressed due to the
“emotional toll” of his conditions. Id. The ALJ noted Plaintiff’s testimony that he could “walk a
couple of blocks and intermittently using walking crutches which he obtained in the beginning of
2020 or 2021, and which Plaintiff stated were recommended by his osteopath.4 R. 30. Plaintiff
represented that he could lift and carry less than 8 pounds comfortably and sit for between 20
minutes and an hour, depending on pain. Id. The ALJ noted that Plaintiff testified that he lives
with his brother, drives about three times a week, and that his brother and mother help him with
daily activities. Id.
Although the ALJ concluded that the “medically determinable impairments could
reasonably be expected to cause the alleged symptoms,” she discounted Plaintiff’s statements
concerning the “intensity, persistence and limiting effects,” as “not entirely consistent with the
medical evidence and other evidence in the record. . . .” Id. In addressing the objective medical
evidence, the ALJ cited a March 13, 2020 MRI of the lumbar spine, which showed “multilevel
disc disease which caused mild canal stenosis and mild foraminal narrowing at L1-L2, moderate
canal stenosis and mild foraminal narrowing at L4-L5, and mild foraminal narrowing at L5-L6.”
Id. The ALJ noted that there was “no mention of or other indications consistent with nerve root
involvement or impingement.” Id. An MRI of the thoracic spine taken the same day showed
“multilevel degenerative changes with no more than minimal canal stenosis.” Id. (citing Ex. 3F).
The ALJ also noted a subsequent MRI of Plaintiff’s cervical spine, performed on
February 11, 2021, indicated “no foraminal or canal stenosis and no signal or cord abnormalities
4 In her discussion, the ALJ noted that she had been unable to locate any recommendation for
such assistive devices in the record and that Plaintiff’s representative “acknowledged that
nothing in the record supported this testimony[.]” R. 30, n.1.
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but was positive for dextroscoliosis at 60 degrees.” Id.
The ALJ found that there was no medical evidence in the record consistent with
Plaintiff’s testimony that he attended physical therapy and received injections for back pain, and
noted that during a “Men’s Preventative Visit” with his primary care provider on October 25,
2021, “physical examination findings were unremarkable,” with the exception of thoracic spasm.
Id. The ALJ also noted that while Plaintiff complained of testicular pain on April 27, 2022, he
refused to go to the Emergency Department despite the recommendation of his primary care
provider. Id.
The ALJ cited a repeat MRI of the lumbar spine on July 8, 2022, noting the finding of “a
disc bulge at L4-L5 encroaching into the neural foramina bilaterally with resultant moderate
foraminal narrowing. Bilateral facet hypertrophy resulted in a mild degree of spinal stenosis.” R.
31 (citing Ex. 15F). The MRI also showed that at L5-S1, there was a “central disc protrusion
with annual [sic] tear slightly indenting the thecal sac resulting in moderate bilateral foraminal
narrowing but no spinal stenosis.” Id. The ALJ noted that there was “no indication of
exacerbation or progression from the prior study.” Id.
The ALJ also discussed the examination of Plaintiff that occurred on September 6, 2022,
two months after the date last insured, in which he complained of chronic back pain. R. 31. He
reported experiencing a stabbing pain in his back near the sacroiliac joint that he experienced
after playing with and chasing his son, describing the pain level as 8 out of 10, worsening with
driving or moving. Id. The ALJ noted that on examination, Plaintiff was comfortable lying down,
but exhibited some discomfort moving, and straight leg raise testing was negative, and “there
were no other abnormalities on physical examination.” Id. (citing Ex. 4F/3).
As for Plaintiff’s mental impairments, the ALJ noted that prior to being involuntarily
10
hospitalized on May 30, 2021, there was no evidence of treatment or evaluation. R. 31. The ALJ
noted that he had been prescribed Zyprexa, Abilify, Wellbutrin, and Suboxone, but had not been
compliant with his medication. Id. He had been abusing marijuana, CBD oil, and mushrooms to
control his mental illness. Id. During the intake evaluation on May 30, 2021, Plaintiff was
“found to be extremely bizarre, preoccupied, uncooperative, responding to internal stimuli,” as
well as “disheveled, guarded, withdrawn, fidgety and restless,” “depressed and Dysphoric, with
flat affect, poor judgment and insight, and paranoid thought content.” Id. After admission,
Plaintiff refused medications and had to be restrained, continuing to be “irritable, grossly
disorganized, intrusive,” and refusing medication. Id. By June 9, 2021, he became calmer and
more lucid, and after taking Haldol for agitation, he reported feeling “good.” Id. He was
discharged in stable condition on June 10, 2021, and his behavior was good and he appeared
calm, and he was referred to Serenity Oaks in Florida for marijuana use/dependence disorder. Id.
On discharge, he was prescribed Neurontin 300 mg, Haldol 5 mg as needed for agitation, Vistaril
50 mg as needed for anxiety, and Trazadone for sleep. Id. His discharge diagnoses were
unspecified psychotic disorder and hallucinogen use disorder. Id. (citing Ex. 2F).
On August 26, 2021, Plaintiff attended an intake evaluation at Richard Hall Community
Counseling (“Richard Hall”), where he acknowledged using medical marijuana as well as
homemade tinctures from mushrooms he found in the woods. R. 32. He stated that he believed
his psychotic symptoms had been brought on by marijuana use, although he claimed ongoing
depression. Id. The mental status evaluation was normal, scoring a 7 on the PHQ-9 depression
inventory screen, indicating “minimal depression symptoms,” and he did claim chronic back pain
for which he was being followed by specialists. Id.
The ALJ referenced an October 6, 2021 psychiatric evaluation at Richard Hall, where he
11
reported not using marijuana since his hospitalization. Id. His mental status evaluation was
normal except for his self-reported decrease in sleep. Id. He was assessed with psychotic
symptoms caused by medical marijuana use, but was no longer having psychosis and no longer
taking Zyprexa. Id. He was diagnosed with depression and his Wellbutrin was changed to
Wellbutrin SR, and his Trazadone was increased. Id. (citing Ex. 5F/1). Subsequent visits for
medication management noted few or no symptoms, although he had issues with his wife from
whom he had separated. R. 32. On November 12, 2021, his mental status examination was
normal except for a “sour” mood when dealing with his wife. Id. Plaintiff was maintaining his
CDL license but was not driving commercially.
The ALJ cited an examination in January 2022 where Plaintiff reported that he was
“doing well and feel like I’m improving by leaps and bounds.” R. 32. “Mental status
examination was unremarkable.” Id. In August 2022, shortly after the date last insured,
Plaintiff’s mental status examination was “normal,” except for a “flat mood and some irritability
in regard to his wife;” they were going through a divorce. Id. The ALJ noted that since January
2022, Plaintiff had been receiving telehealth counseling from SAFE in relation to domestic
abuse, and in a letter dated October 18, 2022, SAFE indicated that Plaintiff had been compliant
in attending both group and individual appointments and “appeared to be making progress
toward his therapy goals.” Id. (citing Ex. 6F).
Following his recitation of the above record evidence, the ALJ stated:
The above evidence is not consistent with the claimant’s testimony. Although the
claimant testified that he is able to stand for only moments and is extremely limited
in lifting and walking, the record notes that shortly after the date last insured, he
was playing with and chasing his son around for several days, and was engaging in
activities such as cooking. There are no specialist or physical therapy notes in the
record, despite the claimant’s testimony that he attended therapy and received
injections related to back pain. Primary care notes do not support the severity of
spinal symptoms alleged by the claimant, and there are only sporadic complaints
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by the claimant. (Ex. 4F). Although the claimant testified that he ambulates with
two canes which were recommended by a doctor, there is no evidence of such
recommendation by any physician. In addition, there are no examination findings
indicating gait dysfunction, abnormal stance, weakness, or reduced range of motion
and straight leg raise testing is consistently negative. (Ex. 4F).
R. 32–33.
The ALJ also noted that “Reviewing medical and psychological consultants for the
Disability Determination Service (DDS) found no severe physical impairments and insufficient
evidence to rate the claimant’s mental limitations at both the initial and reconsideration levels.”
R. 33. The ALJ found these opinions “not persuasive as later received evidence and the hearing
testimony support the existence of severe physical limitations, based primarily on imaging
studies, as well as sufficient mental health evaluation and treatment notes to assess the part “B”
criteria of the applicable mental listings.” R. 33.
V. DISCUSSION
Plaintiff challenges the ALJ’s RFC determination, arguing that the ALJ failed to
adequately explain from the evidence of record the basis upon which the ALJ relied in reaching
her assessment of Plaintiff’s RFC. Pl. Br. at 6–12. The Court agrees that the mental RFC
determination requires remand, but for reasons different than those raised by Plaintiff. See Bryan
P. v. Comm’r of Soc. Sec., No. 1:22-CV-05496, 2023 WL 7151223, at *6–7 (D.N.J. Oct. 31,
2023) (“District courts regularly interpret Sims [v. Apfel, 530 U.S. 103, 110–11 (2000)] to allow
for sua sponte review of issues not raised by the parties in the SSA context.”) (collecting cases);
West v. Kijakazi, No. 3:21-CV-01350, 2023 WL 2742746, at *4 n.3 (M.D. Pa. Mar. 31, 2023)
13
(“A reviewing court may sua sponte address issues in social security cases.”) (quoting Sparaney
v. Kijakazi, No. 3:20-cv-02054, 2022 WL 969619, at *9 n.9 (M.D. Pa. Mar. 30, 2022)).5
A claimant’s RFC is the most the claimant can do despite his or her limitations. 20 C.F.R.
§ 404.1545(a)(1). At the administrative hearing stage, the administrative law judge is charged
with determining the claimant’s RFC. 20 C.F.R. § 404.1546(c); see also Chandler v. Comm’r of
Soc. Sec., 667 F.3d 356, 361 (3d Cir. 2011) (“The ALJ—not treating or examining physicians or
State agency consultants—must make the ultimate disability and RFC determinations.”)
(citations omitted). When determining a claimant’s RFC, the ALJ has a duty to consider all the
evidence. Plummer v. Apfel, 186 F.3d 422, 429 (3d Cir. 1999). The ALJ need include only
“credibly established” limitations in the RFC. Rutherford v. Barnhart, 399 F.3d 546, 554 (3d Cir.
2005); see also Zirnsak v. Colvin, 777 F.3d 607, 615 (3d Cir. 2014) (stating that the ALJ has
discretion to choose whether to include “a limitation [that] is supported by medical evidence, but
is opposed by other evidence in the record”). However, “[t]his discretion is not unfettered—the
ALJ cannot reject evidence of a limitation for an unsupported reason” and stating that “the ALJ
also has the discretion to include a limitation that is not supported by any medical evidence if the
ALJ finds the impairment otherwise credible”).
5 Plaintiff also argues that the ALJ’s physical RFC limitations are inconsistent with the record
and argues that the ALJ should have further developed the record. However, having found
another basis to remand this action, the Court does not reach Plaintiff’s other arguments. See
Stephen S. v. Comm’r of Soc. Sec., No. 24-CV-10055 (CPO), 2025 WL 2962465, at *6 (D.N.J.
Oct. 20, 2025) (“Because the Court concludes that this matter must be remanded for further
proceedings based on the ALJ’s denial of Plaintiff’s right to cross-examine Dr. Lazarus, the
Court need not reach Plaintiff’s remaining arguments on appeal.”); Charran v. Saul, 509 F.
Supp. 3d 80, 87 n.3 (D.N.J. 2020) (“Because the Court remands the action on this basis, the
Court declines to address Plaintiff’s other arguments raised in the merits briefs, ECF Nos. 16, 17,
18.”).
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In the case presently before the Court, the ALJ’s recitation of the evidence above reflects
that the ALJ appeared to find that Plaintiff, with the exception of his psychiatric hospitalization
from May 30, 2021, to June 10, 2021, had generally normal mental status examinations. R. 29–
33. Nevertheless, the ALJ fashioned a RFC with several mental functional limitations:
After careful consideration of the entire record, the undersigned finds that, through
the date last insured, the claimant had the residual functional capacity to perform
light work as defined in 20 CFR 404.1567(b) except the individual can never climb
ladders, ropes, or scaffolds; can perform other postural maneuvers occasionally;
must avoid concentrated exposure to driving vehicles, unprotected heights, and
moving machinery; can have only occasional interaction with supervisors,
coworkers, and the general public and cannot perform work involving shared tasks
with coworkers; any work must be in a low stress job which is defined as having
only occasional decision making and occasional changes in the work setting; can
understand, remember, and carry out detailed but uninvolved written or oral
instructions; no work involving assembly line work or hourly quotas; and any work
must be as self-paced as possible meaning that any production requirements can be
accomplished by the end of the workday or work shift.
R. 29.
In explaining these mental limitations, the ALJ stated that although Plaintiff experienced
“psychotic symptoms and schizoaffective features shortly before his hospitalization in May of
2021, he recovered during his admission, and has not had a recurrence of these symptoms since
his discharge.” R. 33. The ALJ also stated that the “treating notes contain self-reports of
improvement with medication compliance, and normal mental status examination findings.” Id.
However, this explanation does not address how the ALJ determined the mental functional
limitations, including, inter alia, that Plaintiff can have only occasional interaction with
supervisors, coworkers and the general public; cannot perform work involving shared tasks with
coworkers; that any work must be in a low stress job which is defined as having only occasional
decision making and occasional changes in the work setting; and that Plaintiff can understand,
remember, and carry out detailed but uninvolved written or oral instructions. R. 29, 33.
15
Plaintiff correctly notes that there is nothing in the ALJ’s decision that explains the basis
for these proposed limitations. Nowhere in the recitation of the medical evidence discussed by
the ALJ is there any reference to why she found “occasional” interaction with coworkers and
supervisors to be appropriate instead of limited interaction or no interaction. Similarly, there is
no cited explanation for why the ALJ found “low stress” work appropriate or why the ALJ
concluded that the Plaintiff could engage in “occasional decision making” or handle “occasional
changes.”
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).
By not explaining how the medical record supported the various mental limitations
included in the RFC, the ALJ failed to build a “logical bridge” between the evidence and her
decision. See Bienkowski v. Bisignano, No. 4:24-CV-1714, 2025 WL 1668328, at *7 (M.D. Pa.
June 12, 2025) (“[A]s part of the ALJ’s duty of articulation, the ALJ must establish a logical
16
bridge between the evidence and the ALJ’s legal conclusions and factual findings.”); Glenda M.
v. Comm’r Soc. Sec., Civ. No. 22-03137, 2023 WL 6387515, at *6 (D.N.J. Sep. 29, 2023) (“An
ALJ need not specifically address every piece of evidence, but must provide a ‘logical bridge’
between the evidence and [his] conclusions.”) (quoting O’Connor-Spinner v. Astrue, 627 F.3d
614, 618 (7th Cir. 2010)). Moreover, the ALJ’s failure in this regard takes on greater significance
considering Plaintiff’s argument that the medical record also reflects that he “was repeatedly
noted having ‘emotional block’ barriers to learning.” Pl. Br. at 11 (citing R. 376, 397, 406, 783).
Given the present record and the lack of a sufficient explanation as to how she arrived at the
mental RFC limitations, the Court is unable to follow the ALJ’s reasoning. See Bienkowski, 2025
WL 1668328, at *7; Glenda M., 2023 WL 6387515, at *6.
The lack of clarity in the ALJ’s reasoning therefore requires remand. While it is true that
the ALJ need not use “particular language or adhere to a particular format” when considering
opinion evidence, the ALJ must still provide a “discussion of the evidence” and an “explanation
of reasoning” “sufficient to enable meaningful judicial review.” Diaz, 577 F.3d at 504 (internal
quotation marks and citations omitted); see also Sanford v. Comm’r of Soc. Sec., No. CIV. 13-
0366 NLH, 2014 WL 1294710, at *2 (D.N.J. Mar. 28, 2014) (“The Third Circuit has held that
access to the Commissioner’s reasoning is [ ] essential to a meaningful court review.”) (citing
Gober v. Matthews, 574 F.2d 772, 776 (3d Cir. 1978)).
In this particular case, without engaging in the work of the ALJ, this Court cannot
determine which of the medical findings in this recitation led the ALJ to her determination of
Plaintiff’s mental functional limitations. See also Messina v. Comm’r of Soc. Sec., 844 F. App’x
586, 589–90 (3d Cir. 2021) (“Yet we cannot reweigh the evidence or make our own factual
determinations.”) (citations omitted); Chandler v. Comm’r of Soc. Sec., 667 F.3d 356, 359 (3d
17
Cir. 2011) (“Courts are not permitted to reweigh the evidence or impose their own factual
determinations [under the substantial evidence standard].”); Hatton v. Comm’r of Soc. Sec.
Admin., 131 F. App’x 877, 880 (3d Cir. 2005) (“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)).
In short, the ALJ’s failure to explain how she reached the specific mental limitations
from the medical evidence upon which she relied precludes meaningful judicial review based on
the present record in this particular case. See Brownsberger v. Kijakazi, No. 3:20-CV-01426,
2022 WL 178819, at *7 (M.D. Pa. Jan. 18, 2022) (remanding where, among other things, the
“ALJ d[id] not provide any citations to specific evidence on the record to explain his reasoning. .
. .”).
In sum, without further explanation, the Court simply cannot determine from this record
if substantial evidence supports the ALJ’s mental RFC limitations. This Court therefore
concludes that remand of the matter for further consideration of these issues is appropriate.
VI. CONCLUSION
For these reasons, the Court REVERSES the Commissioner’s decision and REMANDS
the matter for further proceedings consistent with this Opinion and Order.
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: August 6, 2026 s/Cheryl L. Pollak
CHERYL L. POLLAK
UNITED STATES MAGISTRATE JUDGE
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