Case Name in Social Security Case - Unavailable

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NOT FOR PUBLICATION
UNITED STATES DISTRICT COURT
DISTRICT OF NEW JERSEY
P.N.,
Plaintiff,
v.
COMMISSIONER OF
SOCIAL SECURITY,
Defendant.
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Civil Action No. 24-11391 (SRC)
OPINION
CHESLER, District Judge
This matter comes before the Court on the appeal by Plaintiff P.N. (“Plaintiff”) of the final
decision of the Commissioner of Social Security (“Commissioner”) determining that he was not
disabled under the Social Security Act (the “Act”). This Court exercises jurisdiction pursuant to
42 U.S.C. § 405(g) and, having considered the submissions of the parties without oral argument,
pursuant to L. CIV. R. 9.1(b), finds that the Commissioner’s decision will be vacated and remanded.
In brief, this appeal arises from Plaintiff’s application for disability insurance benefits, filed
August 25, 2020, alleging disability beginning July 1, 2019. 	The claim was denied initially on
August 9, 2021 and upon reconsideration on March 17, 2022. Plaintiff then filed a written request
for a hearing, which was held before ALJ Kenneth Ayers (the “ALJ”) on November 30, 2022. The
ALJ issued an unfavorable decision on March 16, 2023. Plaintiff sought review of the decision
from the Appeals Council. 	After the Appeals Council denied Plaintiff’s request for review, the
ALJ’s decision became the Commissioner’s final decision, and Plaintiff filed this appeal.
In the March 16, 2023 decision, the ALJ found that, at step three, Plaintiff did not meet or
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equal any of the Listings. At step four, the ALJ found that Plaintiff retained the residual functional
capacity to perform a full range of work at all exertional levels as defined in 20 C.F.R. 404.1567(b),
with certain additional nonexertional limitations. 	At step four, the ALJ also found that Plaintiff
was unable to perform any past relevant work. 	At step five, the ALJ determined, based on the
testimony of a vocational expert, that there are other jobs existing in significant numbers in the
national economy that the claimant can perform, consistent with his medical impairments, age,
education, past work experience, and residual functional capacity. 	The ALJ concluded that
Plaintiff has not been disabled within the meaning of the Act.
On appeal, Plaintiff argues that the Commissioner’s decision should be reversed and
remanded because, at step four, the RFC determination is not supported by substantial evidence
because the ALJ failed to 1) properly evaluate the limitations from Nevins’s mental impairments
and 2) include limitations from Nevins’s headaches.
In reviewing the ALJ’s determination, this Court must affirm the Commissioner’s final
decision if it is “supported by substantial evidence.” 42 U.S.C. § 405(g). “Courts are not permitted
to re-weigh the evidence or impose their own factual determinations.” 	Chandler v. Comm'r of
Soc. Sec., 667 F.3d 356, 359 (3d Cir. 2011). Further, on appeal, Plaintiff carries twin burdens of
proof. First, Plaintiff bears the burden at the first four steps of the analysis of demonstrating how
his impairments, whether individually or in combination, amount to a qualifying disability. Bowen
v. Yuckert, 482 U.S. 137, 146 n.5 (1987). Second, Plaintiff bears the burden of showing not merely
that the Commissioner erred, but also that the error was harmful. Shinseki v. Sanders, 556 U.S.
396, 409 (2009). At the first four steps, this requires that Plaintiff show that, but for the error, he
might have proven his disability. In other words, when appealing a decision at the first four steps,
if Plaintiff cannot articulate the basis for a decision in his favor, based on the existing record, he
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is quite unlikely to show that an error was harmful.
For a district court to be able to find that an ALJ’s opinion is supported by substantial
evidence, that ALJ must explain his reasoning such that his determination is amenable to
meaningful review. See Burnett v. Comm’r of Soc. Sec., 220 F.3d 112, 119 (3d Cir. 2000). While
the ALJ is not required to “use particular language or adhere to a particular format in conducting
his analysis,” she must provide “sufficient . . . explanation of findings to permit meaningful
review.” Jones v. Barnhart, 364 F.3d 501, 505 (3d Cir. 2004).
This Court is not persuaded by Plaintiff’s first argument that the ALJ failed to properly
evaluate the limitations from his mental impairments, because Plaintiff failed to articulate what
exactly the ALJ did that was improper and which rule or point of law was violated by what was
done. Moreover, at step four, Plaintiff does not identify the “admitted mental limitations” that he
contends were omitted and cites no law that imposes on the Commissioner a requirement to explain
why the mental limitations do not have a greater impact on his ability to work. Plaintiff, in essence,
asks this Court to review the record 	de novo 	and reweigh the evidence, which it may not do. The
Third Circuit has held:
A federal court's substantial-evidence review is “quite limited.” 	Rutherford v.
Barnhart, 399 F.3d 546, 552 (3d Cir. 2005). A court may not weigh the evidence
or substitute its own findings for the Commissioner's. 	Monsour Med. Ctr. v.
Heckler, 806 F.2d 1185, 1190-91 (3d Cir. 1986). [Plaintiff's] arguments amount to
a request to reweigh the evidence and review the Commissioner's findings and
decision 	de novo.
Davern v. Comm'r of Soc. Sec., 660 Fed. Appx. 169, 173-74 (3d Cir. 2016). See also Williams v.
Sullivan, 970 F.2d 1178, 1182 (3d Cir. 1992) (“Neither the district court nor this court is
empowered to weigh the evidence or substitute its conclusions for those of the fact-finder.”). At
step four, § 405(g) tasks this Court only with evaluating whether the factual determinations on
which the RFC determination is made are supported by substantial evidence, which simply
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requires a finding of “such relevant evidence as a reasonable mind might accept as adequate to
support a conclusion.” 	Richardson v. Perales, 402 U.S. 389, 401 (1971). 	Since Plaintiff’s
argument concerning the ALJ’s determinations about “mental limitations” essentially asks this
Court to reweigh the evidence, it is without merit.
Plaintiff also recites the ALJ’s findings concerning the paragraph B criteria of the 12.00
Listings at step three. (Pl.’s Br. at 28-29.) Plaintiff does not, however, explain the relevance of
the step three paragraph B findings to the RFC determination at step four. Under Third Circuit
law:
[N]o 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. . . . 	In
short, 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). Pursuant to Hess, the ALJ’s findings
at step three do not necessarily translate into particular findings at step four. 	The “arguments”
section of Plaintiff’s opening brief begins with a challenge to the RFC determination at step four,
but then, without explanation, jumps to the discussion of the paragraph B criteria at step three. As
just explained, under Third Circuit law, the analyses at steps three and four are “distinct.” 	931
F.3d at 209.
To the extent that Plaintiff challenges the Commissioner’s step three determination that
Plaintiff does not meet any of the Listings, Plaintiff’s argument suffers from two principal defects:
1) its failure to deal with the issue of the burden of proof at the first four steps of the sequential
evaluation process; and 2) its failure to deal with the harmless error doctrine. As to the burden of
proof, Plaintiff bears the burden in the first four steps of the analysis of demonstrating how his
impairments, whether individually or in combination, amount to a qualifying disability. Bowen v.
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Yuckert, 482 U.S. 137, 146 n.5 (1987).
As to the harmless error doctrine, the Supreme Court explained its operation in a similar
procedural context in Shinseki v. Sanders, 556 U.S. 396, 409 (2009), which concerned review of
a governmental agency determination. The Court stated: “the burden of showing that an error is
harmful normally falls upon the party attacking the agency’s determination.” Id. In such a case,
“the claimant has the ‘burden’ of showing that an error was harmful.” Id. at 410.
Plaintiff thus bears the burden, on appeal, of showing not merely that the Commissioner
erred, but also that the error was harmful. 	At the first four steps, this requires that Plaintiff also
show that, but for the error, she might have proven her disability. In other words, when appealing
a decision at the first four steps, if Plaintiff cannot articulate the basis for a decision in her favor,
based on the existing record, she is quite unlikely to show that an error was harmful. Plaintiff’s
challenge to the step three determination fails to meet the requirements of Shinseki: Plaintiff has
not identified a specific Listing that the ALJ overlooked, nor did Plaintiff muster evidence of
record that might support a determination at step three that he met the requirements of that specific
Listing. 	Having not offered either, Plaintiff cannot demonstrate that any error at step three was
harmful.
Next, we turn to Plaintiff’s second argument that the ALJ’s decision should be vacated
because he failed to include limitations from Plaintiff’s headaches. This Court finds that the ALJ
erred at step two in determining that Plaintiff’s headaches were not a medically determinable
impairment, and at step four because he failed to evaluate whether they had an impact on Plaintiff’s
RFC. 	While the ALJ references the headaches in his RFC determination, he did not make a
determination as to whether or not they impacted Plaintiff’s ability to work. Thus, with regard to
the headaches, the Court lacks the information it needs to assess whether the ALJ’s decision to
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omit consideration of the headaches at step four is supported by substantial evidence.
At step two, the ALJ found that the headaches were not medically determinable ailments
under SSR 19-4p. The Social Security Administration issued SSR 19-4p to “explain [its] policy
on how [it] establish[es] that a person has an MDI [Medically Determinable Illness] of a primary
headache disorder and how [it] evaluate[s] primary headache disorders in disability claims.”
SSR 19-4p. SSR 19-4p defines primary headache disorders as:
a collection of chronic headache illnesses characterized by repeated exacerbations
of overactivity or dysfunction of pain- sensitive structures in the head. Examples of
common primary headaches 	include 	migraines, 	tension-type 	headaches, and
trigeminal autonomic cephalalgias. They are typically severe enough to require
prescribed medication and sometimes warrant emergency department visits. SSR
19-4p(1).
SSR 19-4p provides the following definitions of tension-type headaches and migraines:
“Migraines 	are vascular headaches involving throbbing and pulsating pain caused
by the activation of nerve fibers that reside within the wall of brain blood vessels
traveling within the meninges (the three membranes covering the brain and spinal
cord). There are two major types of migraine: 	Migraine with aura 	and 	migraine
without aura. Migraine with aura is accompanied by visual, sensory, or other
central nervous system symptoms. Migraine without aura is accompanied by
nausea, vomiting, or photophobia (light sensitivity) and phonophobia (sound
sensitivity). Migraine without aura is the most common form of migraine.” SSR
19-4p(1).
Tension-type headaches 	are characterized by pain or discomfort in the head, scalp,
face, jaw, or neck, and are usually associated with muscle tightness in these areas.
There are two types of tension-type headaches: episodic and chronic. Episodic
tension-type headaches are further divided into infrequent episodic tension-type
headaches, which typically do not require medical management, and frequent
episodic tension-type headaches, which may require medical management. Chronic
tension-type headaches generally evolve from episodic tension-type headaches.
Chronic tension-type headaches and frequent episodic tension-type headaches may
be disabling 	depending 	on the 	frequency 	of 	the headache attacks, 	type of
accompanying symptoms, response to treatment, and functional limitations.
SSR 19-4p(1). 	Under SSR 19-4p, a primary headache disorder is established as an MDI by
“considering objective medical evidence (signs, laboratory findings, or both) from an AMS
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[Acceptable Medical Source].” SSR 19-4p(7). Only a primary, not secondary, headache disorder
may be established as an MDI. The following findings made by an AMS should be considered in
establishing a primary headache disorder as an MDI: 1) A primary headache disorder diagnosis
from an AMS; 2) An observation of a typical headache event, and a detailed description of the
event including all associated phenomena, by an AMS; 3) Remarkable or unremarkable findings
on laboratory tests; and 4) Response to treatment. 	Id. 	SSR 19-4p notes that “[w]hile imaging may
be useful in ruling out other possible causes of headache symptoms, it is not required for a primary
headache disorder diagnosis.” SSR 19-4p(2).
This Court finds that the ALJ erred at step two because he did not properly evaluate
Plaintiff’s headaches in accordance with SSR 19-4p. At step two, the ALJ determined that Plaintiff
failed to establish that his headaches were an MDI under SSR 19-4p. The ALJ provided the
following summary of the medical record regarding Plaintiff’s headaches:
The claimant has alleged having headaches. 	However, this is a symptom, not
related to a medically determinable impairment. Tension headaches and cervicalgia
were noted at Exhibit 2F. 	In March 2019, a neurologist diagnosed the claimant
with tension headache. 	Neurological examination was normal. 	An MRI of the
brain in April 2019, was unremarkable. (Exhibit 2F). In addition, migraines were
noted by a consultative examiner at Exhibit 5F, based solely on the self-reports of
the claimant. This was a one-time evaluation with no imaging performed. There
were no positive, focal neurological findings on exam.
(Tr. 1631). The ALJ stated that “[t]he medical evidence of record does not meet the criteria of SSR
19-4p for his headaches to be considered a medically determinable impairment.” (Tr. 1631.). This
Court finds that the ALJ erred in this determination that the evidence does not meet the criteria of
SSR 19-4p.
The Court finds sufficient evidence in the medical record to establish a primary headache
diagnosis under SSR 19-4p. On December 26, 2018, Dr. Seth R. Stoller diagnosed Plaintiff with
“intractable” tension headaches, both primary and cervicalgia, occurring daily for a period of two
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years. (Tr. 2341-2345.). Dr. Stoller prescribed gabapentin and physical therapy as treatment. (Id.)
Plaintiff was again diagnosed with headaches on March 9, 2020, by Molly Lawrence, APN,
(Tr.2354), and on April 30, 2020 (Tr. 2355) and March 8, 2021 by Dr. Michael Cannella. 	(Tr.
2407). 	During this time, Plaintiff’s medical providers continued to prescribe gabapentin as
treatment. Plaintiff was also diagnosed with migraine headaches by Dr. Ronald Bagner on April
29, 2021. 	(Tr. 	2375-2378). 	On May 28, 2021, Plaintiff reported severe headaches to Jane
Esposito, Psy.D. 	(Tr. 2379-2381). 	On October 24, 2021 he reported headaches during an
evaluation at the Adult Crisis Center. 	(Tr. 2464-2514). 	Given the medical evidence indicating
that Plaintiff was diagnosed with primary headache disorder by multiple physicians, according to
SSR 19-4p, the ALJ erred in determining that the headaches did not qualify as a severe impairment.
The ALJ erred in the application of SSR 19-4p.
Furthermore, the ALJ’s failure to find that the headaches were a severe impairment at step
two is an error under Third Circuit law. The Third Circuit has interpreted the relevant Rulings and
Regulations to hold that “[t]he 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). The Newell
Court further emphasized:
An impairment or combination of impairments can be found “not severe” only if
the 	evidence 	establishes 	a 	slight 	abnormality 	or 	a 	combination 	of 	slight
abnormalities which have “no more than a minimal effect on an individual’s ability
to work.” 	SSR 85-28, 1985 SSR LEXIS 19 at *6-8. 	Only those claimants with
slight abnormalities that do not significantly limit any “basic work activity” can be
denied benefits at step two. 	See Bowen, 482 U.S. at 158 (O'Connor, J., concurring).
If the evidence presented by the claimant presents more than a “slight abnormality,”
the step-two requirement of “severe” is met, and the sequential evaluation process
should continue. 	See Smolen v. Chater, 80 F.3d at 1290. Reasonable doubts on
severity are to be resolved in favor of the claimant.
Newell, 347 F.3d at 546; accord McCrea v. Comm'r of Soc. Sec., 370 F.3d 357, 360 (3d Cir. 2004)
(“The burden placed on an applicant at step two is not an exacting one. . . . Any doubt as to whether
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this showing has been made is to be resolved in favor of the applicant.”). 	In McCrea, the Third
Circuit reaffirmed the severity standard announced in Newell and added that, in light of the low
threshold for severity, findings that an impairment is not severe “should be reviewed with close
scrutiny” and are “certain to raise a judicial eyebrow.” McCrea, 370 F.3d at 357. Therefore, based
upon the medical record, the ALJ should have found that Plaintiff’s headaches were a severe
impairment.
In opposition, Defendant argues that the ALJ considered Plaintiff’s headaches pursuant to
SSR 19-4p. 	That, the Court finds, as already explained, is precisely what the ALJ 	failed 	to do.
Moreover, while the ALJ’s opinion makes reference to Plaintiff’s headaches in his step four
analysis, he does not make any determination as to whether or not the headaches impacted
Plaintiff’s ability to work.
SSR 19-4p(9) provides the following guidance for assessing whether headaches have an
impact on RFC:
If a person's primary headache disorder, alone or in combination with another
impairment(s), does not medically equal a listing at step three of the sequential
evaluation process, we assess the person's residual functional capacity (RFC). We
must consider and discuss the limiting effects of all impairments and any related
symptoms when assessing a person's RFC. The RFC is the most a person can do
despite his or her limitation(s). 19-4p(9).
The ALJ’s opinion does not follow this guidance. In fact, the ALJ’s opinion makes only passing
reference to the headaches in summarizing Plaintiff’s medical history at step four. It fails however,
to assess whether the headaches limited his ability to work, as required by SSR 19-4p.
The ALJ’s failure to make any determination about the limiting effects of Plaintiff’s
headaches constitutes reversible error on two grounds. First, as just explained, the ALJ failed to
follow the requirements of SSR 19-4p. 	Second, it prevents this Court from conducting a
meaningful review of the implicit conclusion that the headaches have no effect on the ability to
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work, because there is no analysis at step four to review. 	The decision is not amenable to
meaningful review under Burnett. Unlike the analysis of Plaintiff’s mental impairments, the ALJ
did not make 	any 	determination regarding the limiting effect of Plaintiff’s headaches. Therefore,
his analysis does not permit meaningful review and the decision must be vacated and remanded,
both for error in the application of SSR 19-4p and because the step four RFC determination is not
amenable to meaningful review under Burnett.
In sum, the ALJ’s failure to determine whether the headaches limited Plaintiff’s ability to
work has made it impossible “to permit meaningful review.” Jones, 364 F.3d at 505. And where
a court cannot meaningfully review an ALJ’s decision, “remand is warranted.” Hendry v. Comm'r
of Soc. Sec., 2018 WL 4616111, at *15 (D.N.J. Sept. 26, 2018).
For the reasons set forth above, this Court finds that the Commissioner erred in the
application of SSR 19-4p and also that the Commissioner's decision is not amenable to meaningful
review, pursuant to Burnett. The decision of the Commissioner is vacated and remanded for further
proceedings in accordance with this Opinion.
s/ Stanley R Chesler
STANLEY R. CHESLER, U.S.D.J.
Dated: October 	, 2026
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