Case Name in Social Security Case - Unavailable

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UNITED STATES DISTRICT COURT
DISTRICT OF NEW JERSEY
RAEMARIE S.
Plaintiff, 	Case No. 3:25-cv-12005
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 Raemarie S. for Disability
Insurance Benefits under Title II of the Social Security Act, 42 U.S.C. §§ 401 et seq., and for
Supplemental Security Income under Title XVI of the Social Security Act, 42 U.S.C. §§ 1381 et
seq. Plaintiff appeals from the final decision of the Commissioner of Social Security denying
Plaintiff’s application.1 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 Frank Bisignano, the Commissioner of Social Security, is substituted as Defendant in his
official capacity.
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I. 	PROCEDURAL HISTORY
On January 8, 2023, Plaintiff filed an application for a period of disability and disability
insurance benefits, along with an application for supplemental security income, alleging that she
had been disabled since an alleged onset date of October 25, 2022. R. 116-19, 243-68. Plaintiff’s
applications were denied initially and upon reconsideration. R. 143-48, 151-58. Plaintiff sought a
de novo hearing before an administrative law judge (“ALJ”). R. 159-61. ALJ Daniel Balutis held
a telephonic hearing on April 18, 2024, at which Plaintiff, who was represented by counsel, Scott
Lawrence Hozakowski Rubi, Esq., testified, as did an impartial vocational expert, Gina Baldwin.
R. 43-80.
In a decision dated June 3, 2024, the ALJ concluded that Plaintiff was not disabled within
the meaning of the Social Security Act from October 25, 2022, the alleged onset date, through
the date of the decision. R. 19-42. That decision became the final decision of the Commissioner
of Social Security when the Appeals Council declined review on April 25, 2025. R. 5-10.
Plaintiff timely filed this appeal pursuant to 42 U.S.C. § 405(g). ECF No. 1. On June 12, 2026,
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. 13.2 The case
was reassigned to the undersigned. ECF No. 14. 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
2 The 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).
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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)).
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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
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(“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
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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),
416.920(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), 416.920(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), 416.920(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. §§
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404.1520(d), 416.920(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. §§ 404.1509, 416.909. 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), 416.920(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), 416.920(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 three months shy of turning 60 years old at the time of the ALJ’s decision.
R. 100 (reflecting date of birth of August 16, 1964, and noting that Plaintiff was 58 years 2
months old on his alleged onset date of October 25, 2022), 108 (same). The ALJ found that
Plaintiff met the insured status requirements of the Social Security Act through March 31,
2028. R. 24. At step one, the ALJ found that the Plaintiff had not engaged in substantial gainful
activity since October 25, 2022, her alleged onset date. Id. The ALJ noted that Plaintiff was hired
as a dental assistant on December 2, 2023, earning $1,685 for the remainder of 2023 and then
earning a total of $4,639 in 2024 through March 17, 2024. R. 24-25. The ALJ explained that
while the earnings for 2023 would exceed the monthly average that is typically indicative of
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substantial gainful activity, as would the earnings for the 2.5 months she worked in 2024, the
work activity qualified as an “unsuccessful work attempt.” R. 25.
At step two, the ALJ found that Plaintiff suffered from the following severe impairments:
coronary artery disease, cardiac abnormality, bilateral sacroiliac joint dysfunction, lumbar
degenerative disc disease and lumbar spondylosis, and sensorineural hearing loss in both ears.
Id. The ALJ also found that the following medically determinable impairments were not severe:
chronic idiopathic constipation, osteoporosis, hypothyroidism, bilateral carpal tunnel, mixed
hyperlipidemia, and prediabetes. R. 25–26.
The ALJ further found that Plaintiff’s “medically determinable mental impairments of
depression and anxiety, considered singly and in combination, do not cause more than minimal
limitation in the claimant’s ability to perform basic mental work activities and are therefore
nonsevere.” R. 26. Based on his analysis of the four paragraph B criteria addressing the four
broad areas of functioning, the ALJ found that Plaintiff’s medically determinable mental
impairments “cause 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,” concluding that they were therefore non-severe. R.
27–29 (emphasis in the original).
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. 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. 29–35. The ALJ also found that the Plaintiff
was able to perform her past relevant work as a medical – laboratory technician, and that this
“work does not require the performance of work-related activities precluded by the claimant’s
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residual functional capacity[.]” R. 35–36. The ALJ therefore concluded that Plaintiff was not
disabled within the meaning of the Social Security Act from October 25, 2022, her alleged onset
date, through the date of the decision. R. 36.
Plaintiff disagrees with the ALJ’s findings at step four and asks that the decision of the
Commissioner be reversed and remanded with direction for the granting of benefits or reversed
and remanded for further proceedings. Plaintiff’s Brief, ECF No. 9 (“Pl. Br.”); Plaintiff’s Reply
Brief, ECF No. 12 (“Pl. Reply”). Specifically, Plaintiff challenges, among other things, the ALJ’s
determination that Plaintiff could return to her prior work as a medical lab technician, a light
exertional position, arguing that, in crafting the RFC and evaluating the impact of her physical
impairments on her ability to perform light work, the ALJ failed to consider physical therapy
records from early 2024. Id. 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. 11 (“D. Br.”).
IV. 	SUMMARY OF ALJ’S FINDINGS AND RELEVANT MEDICAL EVIDENCE
At step three, in considering whether Plaintiff met or medically equaled Listings 1.15 or
1.16, the ALJ first noted that there was no evidence indicating that Plaintiff required an
ambulatory aide that requires use of both extremities, or that she could not perform fine and
gross movements with at least one upper extremity due to a combination of extremity-related
limitations, or that she required the use of a medically necessary mobility device. R. 29.
He then reviewed the requirements for Listing 4.04 for ischemic heart disease and found “no
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medical findings, which meet the criteria of this listing.” Id. 3
At step four, the ALJ concluded that Plaintiff could perform “light” work, “except she
can never climb ladders, ropes, or scaffolds; occasionally climb ramps and stairs; and
occasionally balance, stoop, kneel crouch, and crawl. The claimant can frequently work at
unprotected heights, moving mechanical parts, and operating a motor vehicle. She can frequently
work in weather; humidity and wetness; dust, odors, fumes, and pulmonary irritants; extremes of
cold and heat; exposure to vibration; and in loud noise.” R. 29–30.
In reaching this determination, the ALJ noted, inter alia, evidence related to Plaintiff’s
lumbar degenerative disc disease and lumbar spondylosis. R. 33–34. The ALJ noted that Plaintiff
initiated treatment for a new onset of low back pain with sciatica of the lower extremities in
October 2022 and that a lumbar x-ray at that time showed moderate L4-5 spondylosis. R. 33. The
ALJ noted that a lumbar MRI in November 2022 showed disc bulging and protrusion resulting in
moderate spinal and foraminal stenosis. Id. The ALJ further noted that Plaintiff initially tried
more conservative treatment (medications and epidural steroid injections) without lasting relief.
Id. She therefore underwent a lumbar fusion at L4-5 on April 7, 2023, which improved her
symptoms. Id.
The ALJ also noted that at postoperative follow-up on May 8, 2023, Plaintiff was
3 Plaintiff also raises arguments regarding, inter alia, her mental impairments. See generally Pl.
Br.; Pl. Reply. However, having found that the ALJ’s flawed consideration of the record related
to Plaintiff’s physical impairments requires remand, the Court does not reach Plaintiff’s other
arguments. See Stephen S. v. Comm’r of Soc. Sec., No. 24-CV-10055, 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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ambulating throughout the day and able to do some housework, noting that radicular symptoms
were slowly improving and she was using medical marijuana for pain control. Id. In a follow-up
in June 2023, she reported that she had been doing well, just noting some incisional
pain. Id. The ALJ observed that x-rays showed instrumentation to be in good position and the
surgeon noted that she was doing fine, but spondylosis was still described as degenerative
changes in multiple endplates and facet joints. Id. The surgeon recommended the bone growth
stimulator for nine more months and although she was wearing a brace, it was okay to wean
usage off that. Id.
The ALJ further noted that, by September 2023, Plaintiff had reportedly completed
physical therapy and reported minimal pain. Id. While she continued with some pain, she stated
in a follow-up appointment in December 2023, that it was better now than prior to the surgery
and she admitted that she had actually never had any physical therapy.4 Id. The surgeon thought
she was doing fairly well and recommended physical therapy. (Ex. B14F/3). A computerized
tomography (CT) scan of the lumbar spine at that time still showed spondylosis, including mild
to moderate stenosis, but her fusion looked “fine” and the instrumentation was in good position.
Id.
At a follow-up examination with her surgeon in March 2024, Plaintiff continued to
complain of pain, which was radicular in nature and increased with activity and sitting for long
periods of time. Id. The surgeon observed that she had developed sacroiliac (SI) joint
4 As noted above, in September 2023, Plaintiff reported that she had “completed her physical
therapy,” R. 910, but admitted in December 2023, that “she never had physical therapy because
she had a death in her family[,]” R. 1329. The Court understands this record to mean that
Plaintiff did not complete all the recommended physical therapy following the lumbar fusion on
April 7, 2023. Records indicate that she did receive some physical therapy immediately
following that procedure on April 8, 2023, R. 614–17, 794–97, and April 9, 2023, R. 625–27,
805–08.
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dysfunction and again referred Plaintiff to physical therapy. Id.
The ALJ next highlighted that clinical exams prior to surgery showed lumbar spasms and
tenderness with decreased lumbar range of motion and positive straight leg raise, but there was
no focal deficit or edema and her hips, knees, ankles, and upper and lower legs were all normal.
Id. The ALJ further noted that Plaintiff’s cervical spine exhibited normal range of motion
without pain or tenderness and that gait, sensation, motor function, coordination, and reflexes
were all intact. Id. He went on to observe that the examination at the initial surgical evaluation in
March 2023 showed 4/5 strength of the bilateral extensor hallucis longus (“EHL”) muscles in the
lower legs, but otherwise 5/5 strength, normal sensation and gait, and reduced Achilles reflexes.
Id. A post-operative exam in May 2023 showed steady gait, 5/5 strength, intact sensation, and 1+
reflexes and a post-operative exam in June 2023 showed full range of lumbar motion, ability to
walk on heels and toes, no weakness in the lower extremities, and symmetric deep tendon
reflexes. Id.
The ALJ further highlighted that in September 2023, Plaintiff still had fairly good range
of lumbar motion, ability to tandem walk, no sciatic notch pain, and reflexes were 2+. Id. In
December 2023, a clinical exam showed limited range of lumbar motion, but continued lack of
weakness of the lower extremities, no sensory loss, no pain with straight leg raising, and ability
to walk on heels and toes and normal range of motion in the cervical spine. Id. The ALJ noted
that on clinical exam in March 2024, Plaintiff had pain with special tests such as Patrick’s and
Gaenslen’s signs and pain in the SI joints and decreased sensation distally on her toes. Id.
However, she maintained normal gait and stance otherwise. R. 33–34.
The ALJ therefore concluded that, “[o]verall, the claimant’s pain and findings such as
limited range of motion tend to support exertional, postural, and environmental limitations.
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Although[] allege[d,] reaching limitations are not supported given the claimant’s normal cervical
range of motion and lack of evidence of significant neck pain symptoms as initially alleged.” R.
34.
V. 	DISCUSSION
Plaintiff argues, among other things, that the ALJ erred in crafting a RFC for light
exertional work because she is limited to, at most, sedentary work stemming from her severe
physical impairments, particularly sacroiliitis and radiculopathy. Pl. Br. at 17–20; Pl. Reply at 3.
Plaintiff specifically argues that the ALJ failed to consider notes from a visit on April 8, 2024,
with her treating physical therapist, Chad Kreider. Id. Plaintiff contends that this failure was
harmful legal error, requiring remand. Id. For the reasons that follow, this Court agrees.
“Findings of fact by the [Commissioner] must be accepted as conclusive by a reviewing
court if supported by substantial evidence.” Cotter v. Harris, 642, F.2d 700, 704, *3d Cir. 1981).
Substantial evidence has been defined as “such relevant evidence as a reasoning mind might
accept as adequate to support a conclusion.” Id. (citing Lewis v. Califano, 616 F.2d 73, 76 (3d
Cir. 1980); 42 U.S.C. § 405(g)). 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
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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).
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). A claimant’s RFC is the most the claimant can do despite his or her limitations. 20
C.F.R. § 404.1545(a)(1).
It is well-settled that the ALJ’s decision has to “be accompanied by a clear and
satisfactory explication of the basis on which it rests.” Cotter, 642 F.2d at 704; see also Fargnoli
v. Massanari, 247 F.3d 34, 42 (3d Cir. 2001) (holding that the ALJ is required to “consider and
evaluate the [relevant] medical evidence in the record consistent with his [or her] responsibilities
under the regulations and case law”). The ALJ has a duty to consider all the evidence when
determining a claimant’s RFC, Plummer v. Apfel, 186 F.3d 422, 429 (3d Cir. 1999), but need
only include “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.” Id. While the ALJ has the discretion to include a limitation that is not
supported by any medical evidence “if the ALJ finds the impairment otherwise credible,” “the
ALJ cannot reject evidence of a limitation for an unsupported reason.” Id.
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“In step four, the ALJ must determine whether a claimant’s residual functional capacity
enables [him] to perform his [or her] past relevant work.” Burnett v. Comm’r of Soc. Sec., 220
F.3d 120, 120 (3d Cir. 2000). In conducting this analysis, the ALJ must: (1) “make specific
findings of fact as to the claimant’s residual functional capacity”; (2) “make findings of the
physical and mental demands of the claimant’s past relevant work”; and (3) compare the
claimant’s residual functional capacity to his or her past relevant work to determine whether
claimant is capable of performing the past relevant work. See id. (citing 20 C.F.R. § 404.1561;
S.S.R. 82-62; Winfrey v. Chater, 92 F.3d 1017, 1023 (10th Cir. 1996)). “Similar to the medical
reports, the ALJ must also consider and weigh all of the non-medical evidence before him [or
her].” Burnett, 220 F.3d at 122 (citing Van Horn v. Schweiker, 717 F.2d 871, 873 (3d Cir. 1983);
Cotter, 642 F.2d at 707).
“The claimant is the primary source for vocational documentation, and statements by the
claimant regarding past work are generally sufficient for determining the skill level, exertional
demands and nonexertional demands of such work.” SSR 82-62, 1982 WL 31386, at *3 (Jan. 1,
1982). Determination of the claimant’s ability to perform past relevant work requires a careful
appraisal of:
(1) the individual’s statements as to which past work requirements can no longer
be met and the reason(s) for his or her inability to meet those requirements; (2)
medical evidence establishing how the impairment limits ability to meet the
physical 	and 	mental 	requirements 	of 	the 	work; 	and 	(3) 	in 	some 	cases,
supplementary or corroborative information from other sources such as employers,
the Dictionary of Occupational Titles, etc., on the requirements of the work as
generally performed in the economy.
Id.
In the present case, as previously noted, Plaintiff contends that the ALJ’s failure to
consider physical therapy evidence constitutes reversible error. Pl. Br. at 17–20; Pl. Reply at 3.
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Specifically, on April 8, 2024, Plaintiff presented to Mr. Kreider, a licensed physical therapist,
for an outpatient physical therapy evaluation. R. 1836–41. Upon examination, Mr. Kreider noted
that Plaintiff suffered from “major loss” of lumbar range of motion. R. 1837 (noting “major loss”
in specifically lumbar flexion, lumbar extension, lumbar lateral flexion right, and lumbar lateral
flexion left), 1840 (same). He further noted reduced strength in Plaintiff’s bilateral lower
extremities, including 3+/5 in Plaintiff’s bilateral hip extension and hip abduction. Id. Mr.
Kreider additionally noted that Plaintiff’s straight leg raise test was positive on the right and her
slump test5 was also positive. Id. In evaluating Plaintiff’s mobility and gait, Mr. Kreider noted
that Plaintiff had a “[s]low determined gait pattern with deceased ar[]m swing and trunk
rotation” and that Plaintiff stated that “some days she does not feel steady on her feet. She was
educated on using a cane on those days.” Id. (emphasis in the original). Mr. Kreider further
noted that, under the heading “Functional Reporting/Outcome Tools,” Plaintiff scored very low
on the Lower Extremity Functional Scale (“LEFS”). Id. (reflecting that Plaintiff scored 12 out of
a possible 80).6 Under the heading “Assessment,” Mr. Kreider noted as follows:
Impairments: abnormal gait, abnormal or restricted ROM [range of motion],
activity intolerance, impaired physical strength, lacks appropriate home exercise
program, pain with function, decreased ability to perform ADLs [activities of daily
living], difficulty performing job and impaired functional mobility[.]
Assessment details: + difficulty with adls and household chores. + difficulty with
walking long periods of time. + difficulty with stairs. + difficulty with sleeping +
5 The slump test is “used to determine if there is sciatic nerve impingement[.]” Vitanza o.b.o.
Vitanza v. Berryhill, No. 4:18-CV-0107, 2019 WL 2352141, at *8 (M.D. Pa. May 14, 2019),
report and recommendation adopted sub nom. Vitanza o/b/o Vitanza v. Berryhill, No. 4:18-CV-
00107, 2019 WL 2324570 (M.D. Pa. May 31, 2019).
6 “The LEFS is a questionnaire where plaintiff rated the level of difficulty that [s]he has with
twenty different activities due to [her lower extremity impairment].” Quintana v. Colvin, No. 15
CIV. 6473, 2017 WL 752187, at *6 n.21 (S.D.N.Y. Feb. 27, 2017). A zero out of a possible 80
reflects the greatest impairment, Conti v. The Lincoln Nat’l Life Ins. Co., No. CV 22-1579, 2024
WL 1216386, at *2 (D. Minn. Mar. 21, 2024), while “a higher score indicat[es] higher
functioning.” Giles v. Colvin, No. 1:14-CV-00684 (MAT), 2017 WL 2533191, at *3 n.3
(W.D.N.Y. June 12, 2017).
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difficulty with standing for long periods of time. + difficulty with bending and
squatting + difficulty lifting and carrying. + difficulty with sitting for long periods
of time.
Id. (emphasis in the original). Mr. Kreider noted that Plaintiff’s prognosis was good. Id.
Plaintiff argues that the ALJ never discussed this evidence. Pl. Br. at 19. According to
Plaintiff, this April 2024 physical therapy evidence conflicts with the ALJ’s finding that Plaintiff
was capable of performing her past relevant work, which requires an ability to stand, walk, and
carry for approximately six hours a day. Id. Plaintiff contends that the vocational expert
testimony supports a finding that the ALJ’s failure to consider this evidence requires remand. Id.
at 19–20 (citations omitted).
The Court agrees that the ALJ’s failure in this regard constitutes reversible error. As
detailed above, the ALJ crafted a RFC for light exertional work. R. 29–30. Under the regulations,
light work involves
lifting no more than 20 pounds at a time with frequent lifting or carrying of objects
weighing up to 10 pounds. . . . [A] job is in this category when it requires a good
deal of walking or standing, or when it involves sitting most of the time with some
pushing and pulling of arm or leg controls. To be considered capable of performing
a full or wide range of light work, you must have the ability to do substantially all
of these activities.
20 C.F.R. §§ 404.1567(b). 416.967(b) (emphasis added). More specifically,
[t]he regulations define light work as lifting no more than 20 pounds at a time with
frequent lifting or carrying of objects weighing up to 10 pounds. Even though the
weight lifted in a particular light job may be very little, a job is in this category
when it requires a good deal of walking or standing--the primary difference
between sedentary and most light jobs. A job is also in this category when it
involves sitting most of the time but with some pushing and pulling of arm-hand or
leg-foot controls, which require greater exertion than in sedentary work; e.g.,
mattress 	sewing 	machine operator, 	motor-grader 	operator, 	and 	road-roller
operator (skilled and semiskilled jobs in these particular instances). Relatively few
unskilled light jobs are performed in a seated position. ‘Frequent’ means occurring
from one-third to two-thirds of the time. Since frequent lifting or carrying requires
being on one’s feet up to two-thirds of a workday, the full range of light work
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requires standing or walking, off and on, for a total of approximately 6 hours of
an 8-hour workday. Sitting may occur intermittently during the remaining time.”
SSR 83-10 (emphasis added); see also Jesurum v. Sec’y of U.S. Dep’t of Health & Hum. Servs.,
48 F.3d 114, 119 (3d Cir. 1995) (“The Secretary has further explained this definition [of light
work in the DOT] in Social Security Ruling 83-10 by stating that light work generally requires
the ability to stand and carry weight for approximately six hours of an eight hour day.”).7
Nowhere in his recitation of the evidence relied on when crafting the RFC did the ALJ
discuss—or even acknowledge—Mr. Kreider’s notes from April 2024, documenting, among
other things, significant limitations in Plaintiff’s lumbar back, abnormal gait, impaired strength,
“difficulty with walking long periods of time[,]” “difficulty with standing for long periods of
time[,]” “difficulty lifting and carrying[,]” and “difficulty with sitting for long periods of time.”
R. 30–35, 1837, 1840. In other words, the ALJ did not address evidence that undermines or
could undermine his determination that Plaintiff was capable of performing light exertional
work. Id. Moreover, the ALJ offered no explanation for this omission. R. 30–35. 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).
The ALJ’s omission in this regard and failure to explain this omission take on even
greater significance when one considers the testimony of the vocational expert, upon whom the
7 In contrast, sedentary work requires, inter alia, only approximately two hours out of an eight-
hour workday. 20 C.F.R. §§ 404.1567(a) (explaining that sedentary work involves “lifting no
more than 10 pounds at a time and occasionally lifting or carrying articles like docket files,
ledgers, and small tools. Although a sedentary job is defined as one which involves sitting, a
certain amount of walking and standing is often necessary in carrying out job duties. Jobs are
sedentary if walking and standing are required occasionally and other sedentary criteria are
met”), 416.967(a) (same).
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ALJ relied. R. 35–36, 72–73. The vocational expert testified that Plaintiff’s past relevant work as
a medical - laboratory technician was, inter alia, light exertion as generally performed (and
medium8 exertion as Plaintiff performed it). R. 72. Notably, the vocational expert expressly
stated that Plaintiff would not be able to perform her past relevant work if the exertion level was
reduced from light to sedentary. R. 73.
In sum, without further explanation, the Court simply cannot determine from this record
if substantial evidence supports the ALJ’s RFC determination for light exertional work and,
relatedly, whether Plaintiff was capable of performing her past relevant work as a medical –
laboratory technician as performed generally (light exertional). See Jones v. Barnhart, 364 F.3d
501, 505 (3d Cir. 2004) (stating that the ALJ’s decision must contain “sufficient development of
the record and explanation of findings to permit meaningful review”) (citing Burnett v. Comm’r
of Soc. Sec., 220 F.3d 112, 119 (3d Cir. 2000)); Cotter v. Harris, 642 F.2d 700, 706–07 (3d Cir.
1981) (“Since it is apparent that the ALJ cannot reject evidence for no reason or for the wrong
reason, . . . an explanation from the ALJ of the reason why probative evidence has been rejected
is required so that a reviewing court can determine whether the reasons for rejection were
improper.”) (internal citation omitted).
This Court therefore concludes that remand of the matter for further consideration of
these issues is appropriate.
8 “A full range of medium work requires standing or walking, off and on, for a total of
approximately 6 hours in an 8-hour workday in order to meet the requirements of frequent lifting
or carrying objects weighing up to 25 pounds.” SSR 83-10 (noting further that the regulations
“define medium work as lifting no more than 50 pounds at a time with frequent lifting or
carrying of objects weighing up to 25 pounds”); see also 20 C.F.R. §§ 404.1567(c) (providing
that medium work “involves lifting no more than 50 pounds at a time with frequent lifting or
carrying of objects weighing up to 25 pounds”), 416.967(c) (same).
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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: October 15, 2026 	s/Cheryl L. Pollak
CHERYL L. POLLAK
UNITED STATES MAGISTRATE JUDGE
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