govinfo:USCOURTS-pawd-2_25-cv-00492-0

Corpus: 543,223 opinions · 3,177 judges · newest 2026-06-23 · expanding Coverage ↗

IN THE UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF PENNSYLVANIA

TRICIA IRENE MCGINNESS,

Plaintiff,

LELAND DUDEK
Acting Commissioner of Social Security,

Defendant.

25cv00492
ELECTRONICALLY FILED

MEMORANDUM OPINION
Before the Court is Plaintiff’s Motion for Summary Judgment in this Social Security
matter. ECF 11. Plaintiff, who was denied social security disability benefits, presents two issues
on appeal to this Court: (1) whether the ALJ failed to properly evaluate the opinions of Plaintiff’s
treating providers; and (2) whether the ALJ failed to properly evaluate Plaintiff’s subjective
complaints. ECF 12.
Defendant timely filed a response in opposition to Plaintiff’s motion. ECF 18. In his
brief, Defendant counters that substantial evidence of record: (1) supports the ALJ’s finding that
Plaintiff’s residual functioning capacity (“RFC”) demonstrated that Plaintiff could perform work
which exists in significant numbers in the economy; and (2) supports the ALJ’s evaluation of
Plaintiff’s subjective complaints. ECF 18.
I. BACKGROUND
Plaintiff worked as a server and bartender prior to December 14, 2015. Plaintiff’s
disability purportedly began on December 14, 2015, due to left breast cancer, obesity,

depression, and anxiety disorder. ECF 4-2, p. 25. The ALJ found these to be medically
determinable impairments which significantly limited Plaintiff’s ability to perform basic work
activities. Id. However, the ALJ also found that through the date of last insured, Plaintiff did not
have an impairment or combination of impairments that met or medically equaled the severity of
one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix I. ECF 4-2, p. 26.
Specifically, the ALJ noted that after considering Plaintiff’s physical impairment under 13.10,
Plaintiff’s medical record “did not document locally advanced cancer, recurrent carcinoma,
small-cell carcinoma, secondary lymphedema, or carcinoma with metastases to the
supraclavicular or infraclavicular nodes, 10 or more auxiliary nodes, or distant metastases.” Id.
As for Plaintiff’s obesity impairment, the ALJ noted that under all pertinent listings, the medical
evidence did not “document the level of severity required to meet any listing, and no medical
source opine[d] that the claimant's condition [was] equivalent in severity to the criteria of any
listed impairment.” Id. The ALJ also considered Plaintiff’s mental impairment and found that
when considered “singly or in combination, they did not meet or medically equal the criteria of
listings 12.04 and 12.06.” Id.
Declining to review the ALJ’s decision on this matter, the Appeals Council determined
that there was no evidence that:
(1) the Administrative Law Judge abused her discretion;
(2) there was an error of law;
(3) the decision was not supported by substantial evidence;
(4) there is a broad policy or procedural issue that may affect the public interest;

(5) it had received additional new, material evidence that relates to the period on or
before the date of the hearing decision.
Plaintiff timely filed the instant civil action, and this Court will now review the matter de
novo.

II. STANDARD OF REVIEW
Judicial review of the Commissioner’s final decisions on disability claims is provided by
statute. 42 U.S.C. §§ 405(g)1 and 1383(c)(3)2. Section 405(g) permits a district court to review
transcripts and records upon which a determination of the Commissioner is based. Because the
standards for eligibility under Title II (42 U.S.C. §§ 401-433, regarding Disability Insurance
Benefits, or “DIB”), and judicial review thereof, are virtually identical to the standards under
Title XVI (42 U.S.C. §§ 1381-1383f, regarding Supplemental Security Income, or “SSI”),
regulations and decisions rendered under the Title II disability standard, 42 U.S.C. § 423, are

1 Section 405(g) provides in pertinent part:

Any individual, after any final decision of the [Commissioner] made after a hearing
to which he was a party, irrespective of the amount in controversy, may obtain a
review of such decision by a civil action . . . brought in the district court of the
United States for the judicial district in which the plaintiff resides, or has his
principal place of business. . .

42 U.S.C. § 405(g).
2 Section 1383(c)(3) provides in pertinent part:

The final determination of the Commissioner of Social Security after a hearing
under paragraph (1) shall be subject to judicial review as provided in section 405(g)
of this title to the same extent as the Commissioner's final determinations under
section 405 of this title.

42 U.S.C. § 1383(c)(3).

pertinent and applicable in Title XVI decisions rendered under 42 U.S.C. § 1381(a), and vice
versa. Sullivan v. Zebley, 493 U.S. 521, 525 n. 3 (1990); Burns v. Barnhart, 312 F.3d 113, 119
n.1 (3d Cir. 2002).
A. Substantial Evidence
If supported by substantial evidence, the Commissioner’s factual findings must be
accepted as conclusive. Ventura v. Shalala, 55 F.3d 900, 901 (3d Cir. 1995); Wallace
v. Secretary of HHS, 722 F.2d 1150, 1152 (3d Cir. 1983). The district court’s function is to
determine whether the record, as a whole, contains substantial evidence to support the
Commissioner’s findings. See Adorno v. Shalala, 40 F.3d 43, 46 (3d Cir. 1994) (citing
Richardson v. Perales, 402 U.S. 389, 401 (1971). The Supreme Court has explained that
“substantial evidence” means “more than a mere scintilla” of evidence, but rather, is “such
relevant evidence as a reasonable mind might accept as adequate to support a conclusion.”
Richardson, 402 U.S. at 401 (citation omitted). See Rutherford v. Barnhart, 399 F.3d 546, 552
(3d Cir. 2005); Ventura, 55 F.3d at 901 (quoting Richardson); Stunkard v. Secretary of HHS, 841
F.2d 57, 59 (3d Cir. 1988).
The Court of Appeals for the Third Circuit has referred to this standard as “less than a
preponderance of the evidence but more than a mere scintilla.” Burns v. Barnhart, 312 F.3d 113,
118 (3d Cir. 2002) (quoting Jesurum v. Secretary of the Dep’t of Health and Human Servs., 48
F.3d 114, 117 (3d Cir. 1995)). “A single piece of evidence will not satisfy the substantiality test
if the Secretary ignores, or fails to resolve, a conflict created by countervailing evidence.”
Mason v. Shalala, 994 F.2d 1058, 1064 (3d Cir. 1993) (quoting Kent v. Schweiker, 710 F.2d 110,
114 (3d Cir. 1983)). The substantial evidence standard allows a court to review a decision of an

ALJ, yet avoid interference with the administrative responsibilities of the Commissioner. See
Stewart v. Secretary of HEW, 714 F.2d 287, 290 (3d Cir.1983).
In reviewing the record for substantial evidence, the district court does not weigh the
evidence or substitute its own conclusions for those of the fact finder. Rutheford, 399 F.3d
at 552. In making this determination, the district court considers and reviews only those findings
upon which the ALJ based his or her decision, and cannot rectify errors, omissions or gaps in the
medical record by supplying additional findings from its own independent analysis of portions of
the record which were not mentioned or discussed by the ALJ. Fargnoli v. Massarini, 247 F.3d
34, 44 n.7 (3d Cir. 2001) (“The District Court, apparently recognizing the ALJ's failure to
consider all of the relevant and probative evidence, attempted to rectify this error by relying on
medical records found in its own independent analysis, and which were not mentioned by the
ALJ. This runs counter to the teaching of SEC v. Chenery Corp., 318 U.S. 80 (1943), that ‘[t]he
grounds upon which an administrative order must be judged are those upon which the record
discloses that its action was based.’ Id. at 87.”) (parallel and other citations omitted).
An ALJ must do more than simply state factual conclusions, but instead must make
specific findings of fact to support his or her ultimate findings. Stewart v. Sec'y HEW, 714 F.2d
287, 290 (3d Cir. 1983).
B. Five Step Determination Process
In order to qualify for DIB or SSI benefits, the claimant must show “he is unable to
engage in any substantial gainful activity by reason of any medically determinable physical or
mental impairment which can be expected to result in death or which has lasted or can be

expected to last for a continuous period of not less than twelve months.” 42 U.S.C.
§ 1383c(a)(3)(A).
When resolving the issue of whether a claimant is disabled and entitled to either DIB or
SSI benefits, the Commissioner utilizes a five-step sequential evaluation. 20 C.F.R. §§ 404.1520
and 416.920 (1995). See Sullivan, 493 U.S. at 525. The Court of Appeals for the Third Circuit
summarized this five-step process in Plummer v. Apfel, 186 F.3d 422 (3d Cir. 1999):
In step one, the Commissioner must determine whether the claimant is currently
engaging in substantial gainful activity. 20 C.F.R. § 1520(a). If a claimant is found
to be eng aged in substantial activity, the disability claim will be denied. Bowen
v. Yuckert, 482 U.S. 137, 140, 107 S.Ct. 2287, 2290–91, 96 L.Ed.2d 119 (1987). In
step two, the Commissioner must determine whether the claimant is suffering from
a severe impairment. 20 C.F.R. § 404.1520(c). If the claimant fails to show that her
impairments are “severe”, she is ineligible for disability benefits.

In step three, the Commissioner compares the medical evidence of the claimant ’s
impairment to a list of impairment s presumed severe enough to preclude any
gainful work. 20 C.F.R. § 404.1520(d). If a claimant does not suffer from a listed
impairment or its equivalent, the analysis proceeds to steps four and five. Step four
requires the ALJ to consider whether the claim ant retains the residual functional
capacity to perform her past relevant work. 20 C.F.R. § 404.1520(d). The claimant
bears the burden of demonstrating an inability to return to her past relevant work.
Adorno v. Shalala, 40 F.3d 43, 46 (3d Cir.1994).

If the claimant is unable to resume her former occupation, the evaluation moves to
the final step. At this stage, the burden of production shifts to the Commissioner,
who must demonstrate the claimant is capable of performing other available work
in order to deny a claim of disability. 20 C.F.R. § 404.1520(f). The ALJ must show
there are other jobs existing in significant numbers in the national economy which
the claimant can perform, consistent with her medical impairments, age, education,
past work experience, and residual functional capacity. The ALJ must analyze the
cumulative effect of all the claimant's impairments in determining whether she is
capable of performing work and is not disabled. See 20 C.F.R. § 404.1523 . The
ALJ will often seek the assistance of a vocational expert at this fifth step. See,
Podedworny v. Harris, 745 F.2d 210, 218 (3d Cir.1984).

Plummer, 186 F.3d at 428. See also Rutherford, 399 F.3d at 551 (explaining: “In the first four
steps the burden is on the claimant to show that she (1) is not currently engaged in gainful

employment because she (2) is suffering from a severe impairment (3) that is listed in an
appendix (or is equivalent to such a listed condition) or (4) that leaves her lacking the RFC to
return to her previous employment (Reg. §§ 920(a) to (e)). If the claimant satisfies step 3, she is
considered per se disabled. If the claimant instead satisfies step 4, the burden then shifts to the
Commissioner at step 5 to show that other jobs exist in significant numbers in the national
economy that the claimant could perform (Reg. § 920(f)).”).
Further:
When “mental impairments are at issue, additional inquiries are layered on top of
the basic five -step disability analysis.” Hess v. Comm'r Soc. Sec ., 931 F.3d 198,
202 (3d Cir. 2 019). The regulations set forth a “special technique” used for
evaluating mental impairments. See 20 C.F. R. §§ 404.1520a, 416.920a. As part of
that “special technique,” a claimant's degree of functional limitation is rated in four
broad functional areas: understanding, remembering, or applying information;
interacting with others; concentrating, persisting, or maintaining pace; and adapting
or managing oneself. Id. at § 404.1520a(c)(3), 416.920a(c)(3). A claimant's degree
of limitation in these functional areas is rated using “the following five-point scale:
None, mild, moderate, marked, and extreme.” Id. at §§ 404.1520a(c)(4),
416.920a(c)(4). The ratings in these four broad functional areas are used at step 2
to determine if the claimant has a severe mental impairment, and if the claimant has
a severe mental impairment, the ratings are also used at step 3 to determine if the
claimant's severe mental impairment meets or equals a listed mental disorder. Id.
at §§ 404.1520a(d), 416.920a(d).

Walizer v. Dudek, Civ. No. 24-25, 2025 WL 964259, at *4 (M.D. Pa. Mar. 31, 2025).
Thus, a claimant may demonstrate that his or her impairment is of sufficient severity to
qualify for benefits in one of two ways: (1) by introducing medical evidence that the claimant is
disabled per se because he or she meets the criteria for one or more of a number of serious Listed
Impairments delineated in 20 C.F.R. Regulations No. 4, Subpt. P, Appendix 1, or that the
impairment is equivalent to a Listed Impairment; or (2) in the event that claimant suffers from a
less severe impairment, he or she will be deemed disabled where he or she is nevertheless unable

to engage in “any other kind of substantial gainful work which exists in the national economy
. . . .” Heckler v. Campbell, 461 U.S. 458, 460-461 (1983) (citing 42 U.S.C. § 423 (d)(2)(A));
Stunkard, 841 F.2d at 59; Kangas, 823 F.2d at 777 (Steps 1-3)). In order to prove disability
under this second method, plaintiff must first demonstrate the existence of a medically
determinable disability that precludes him or her from returning to his or her former job (Steps
1-2, 4). Stunkard, 841 F.2d at 59; Kangas, 823 F.2d at 777. Then, the claimant having shown
that he or she is unable to resume his or her previous employment, the burden shifts to the
Commissioner (Step 5) to prove that, given plaintiff's mental and/or physical limitations, age,
education and work experience, he or she is able to perform substantial gainful activity in jobs
available in the national economy. Campbell, 461 U.S. at 461; Boone v. Barnhart, 353 F.3d 203,
205 (3d Cir. 2003); Stunkard, 842 F.2d at 59; Kangas, 823 F.2d at 777.
Moreover, the Commissioner/ALJ;
must “explicitly” weigh all relevant, probative and available evidence. . . . [and]
must provide some explanation for a rejection of probative evidence which
would suggest a contrary disposition. . . . The [Commissioner] may properly
accept some parts of the medical evidence and reject other parts, but she must
consider all the evidence and give some reason for discounting the evidence she
rejects.

Adorno, 40 F.3d at 48 (emphasis added; citations omitted). See also Fargnoli, 247 F.3d at 42-43
(although ALJ may weigh conflicting medical and other evidence, he must give some indication
of the evidence he rejects and explain the reasons for discounting the evidence; where ALJ failed
to mention significant contradictory evidence or findings, Court was left to wonder whether he
considered and rejected them, or failed to consider them at all, giving Court “little choice but to
remand for a comprehensive analysis of the evidence consistent with the requirements of the
applicable regulations and the law of this circuit. . . .”); Burnett, 220 F.3d at 121 (“In making a
residual functional capacity determination, the ALJ must consider all evidence before him. . . .
Although the ALJ may weigh the credibility of the evidence, he must give some indication of the
evidence which he rejects and his reason(s) for discounting such evidence. . . . ‘In the absence of
such an indication, the reviewing court cannot tell if significant probative evidence was not
credited or simply ignored.’ Cotter, 642 F.2d at 705.”) (additional citations omitted).
C. Multiple Impairments
Where a claimant has multiple impairments which, individually, may not reach the level
of severity necessary to qualify as a Listed Impairment, the ALJ/Commissioner nevertheless
must consider all of the claimant’s impairments in combination to determine whether,
collectively, they meet or equal the severity of a Listed Impairment. Burnett, 220 F.3d at 122
(“the ALJ must consider the combined effect of multiple impairments, regardless of their
severity”); Bailey v. Sullivan, 885 F.2d 52 (3d Cir. 1989) (“in determining an individual's
eligibility for benefits, the ‘Secretary shall consider the combined effect of all of the individual's
impairments without regard to whether any such impairment, if considered separately, would be
of such severity’”) (citing 42 U.S.C. § 423(d)(2)(C), and 20 C.F.R. §§ 404.1523, 416.923).
Section 404.1523 of the Regulations, titled “Multiple impairments,” provides:

In determining whether your physical or mental impairment or impairments are of a
sufficient medical severity that such impairment or impairments could be the basis of
eligibility under the law, we will consider the combined effect of all of your impairments
without regard to whether any such impairment, if considered separately, would be of
sufficient severity. If we do find a medically severe combination of impairments, the
combined impact of the impairments will be considered throughout the disability
determination process. If we do not find that you have a medically severe combination of
impairments, we will determine that you are not disabled (see § 404.1520).

20 C.F.R. § 404.1523.
Even if a claimant’s impairment does not meet the criteria specified in the listings, he
must be found disabled if his condition is equivalent to a listed impairment. 20 C.F.R.
§ 404.1520(d). When a claimant presents more than one impairment, “the combined effect of the
impairment must be considered before the Secretary denies the payment of disability benefits.”
Bittel v. Richardson, 441 F.2d 1193, 1195 (3d Cir.1971) (citation omitted). To that end, the ALJ
may not just make conclusory statements that the impairments do not equal a listed impairment
in combination or alone, but rather, is required to set forth the reasons for his or her decision, and
specifically explain why he or she found a claimant’s impairments did not, alone or in
combination, equal in severity one of the listed impairments. Fargnoli, 247 F.3d at 40 n. 4 (citing
Burnett, 220 F.3d at 119-20).
If the ALJ or Commissioner believes the medical evidence is inconclusive or unclear as
to whether the claimant is unable to return to past employment or perform substantial gainful
activities, it is incumbent upon the ALJ to “secure whatever evidence [he/she] believed was
needed to make a sound determination.” Ferguson, 765 F.2d at 36.
D. Claimant’s Subjective Complaints of Impairments and Pain
As explained by the court in Schneider v. Berryhill, Civ. No. 17-1299, 2019 WL 698471,
(W.D. Pa. Feb. 20, 2019):
SSR 16-3p went into effect on March 28, 2016. SSR 16-3p supersedes SSR 96-7p,
the previous rule governing the evalua tion of subjective symptoms. See, SSR 16-

3p, 2016 WL 1119029 (March 16, 2016) . SSR 16 -3p removes the term
“credibility,” clarifying that the subjective symptom evaluation is not an
examination of an individual's character but rather an ALJ is to “consider all of the
evidence in an individual's record . . . to determine how symptoms limit ability to
perform work-related activities.” Id. at *2. In so doing, an ALJ is to use a two-step
process. Id. at *2-33. Thus, after an ALJ finds “that the individual has a medically
determinable impairment(s) that could reasonably be expected to produce those
symptoms”, the ALJ shall then consider all of the evidence in the record when
he/she evaluates the intensity and persistenc e of symptoms to determine how
“symptoms limit [the] ability to perform work-related activities.” Id. In this regard,
and to the extent relevant and available, the ALJ should consider objective medical
evidence; individual statements; other medical sources ; non-medical sources; the
factors set forth in 20 C.F.R. § 404.1529(c)(3) and § 416.929(c)(3) including daily
activities; the location, duration, frequency and intensity of pain or other symptoms;
factors that precipitate and aggravate the symptoms; the type, dosage, effectiveness
and side effects of any medication an individual takes or has taken to alleviate pain
or other symptoms; treatment other than medication an individual receives or has
received for relief of pain or other symptoms; any measures ot her than treatment
used to relieve pain or other symptoms; and any other factors concerning an
individual's functional limitations and restrictions due to pain or other symptoms.
Id. at *4-7.

Schneider, 2019 WL 698471, at *2. See also Mason v. Shalala, 994 F.2d 1058, 1067 (3d
Cir.1993) (determining: “An ALJ must give serious consideration to a claimant's subjective
complaints of pain, even where those complaints are not supported by objective evidence.”).

III. STATEMENT OF THE FACTS
Plaintiff applied for Supplemental Security Income alleging her disability began on
December 14, 2015, due to breast cancer, osteopenia, Stage 4 one cancer and Stage 4 lung
cancer. Her claim was initially denied on September 26, 2023, and was again denied on
February 2, 2024. She was next represented by counsel during her June 11, 2024 hearing before
an Administrative Law Judge (“ALJ”). On October 15, 2024, the ALJ issued an unfavorable
opinion, of which the portions relevant to the Court’s review are as follows:

FINDINGS OF FACT AND CONCLUSIONS OF LAW

After careful consideration of the entire record, the undersigned makes the
following findings:

1. The claimant last met the insured status requirements of the Social
Security Act on June 30, 2019.

2. The claimant did not engage in substantial gainful activity during the
period from her alleged onset date of December 14, 2015 through her date
last insured of June 30, 2019 (20 CFR 404.1571 et seq.).

The claimant testified that she worked as a server and bartender during the
relevant period, but there are no reported earnings that rise to the level of
substantial gainful activity (Exhibit 7D).

3. Through the date last insured, the claimant had the following severe
impairments: left breast cancer, obesity, depression, and anxiety disorder (20
CFR 404.1520(c)). The above medically determinable impairments
significantly limit the ability to perform basic work activities as required by
SSR 85-28.

4. Through the date last insured, the claimant did not have an impairment or
combination of impairments that met or medically equaled the severity of
one of the listed impairments in 20 CFR Part 404, Subpart P, Appendix 1 (20
CFR 404.1520(d), 404.1525 and 404.1526).

The undersigned considered the claimant’s physical impairment under listing
13.10. However, through the date last insured, the objective medical evidence
does not document locally advanced cancer, recurrent carcinoma, small-cell
carcinoma, secondary lymphedema, or carcinoma with metastases to the
supraclavicular or infraclavicular nodes, 10 or more auxiliary nodes, or distant
metastases. The undersigned also assessed the claimant’s obesity under all
pertinent listings, but the medical evidence does not document the level of
severity required to meet any listing, and no medical source opines that the
claimant’s condition is equivalent in severity to the criteria of any listed
impairment.

The severity of the claimant’s mental impairments, considered singly and in
combination, did not meet or medically equal the criteria of listings 12.04 and
12.06. In making this finding, the undersigned has considered whether the
“paragraph B” criteria were satisfied. To satisfy the “paragraph B” criteria, the
mental impairments must result in one extreme limitation or two marked
limitations in a broad area of functioning. An extreme limitation is the inability to

function independently, appropriately, or effectively, and on a sustained basis. A
marked limitation is a seriously limited ability to function independently,
appropriately, or effectively, and on a sustained basis.

In understanding, remembering or applying information, the claimant had a mild
limitation. She reported that she cared for her personal needs, drove a vehicle, left
her residence without accompaniment, worked part-time as a bartender and
server, and performed household tasks such as painting, cleaning, shopping, and
preparing meals (Exhibits 2F and 5F; and Testimony). Mental status examinations
describe a pleasant, cooperative, alert, and fully oriented presentation
without abnormalities in mood, affect, appearance, speech, motor activity, eye
contact, manner of relating, insight, judgment, reasoning, perception, attention,
concentration, memory, cognitive functioning, or thought processes from the
alleged onset date through the date last insured. No treating, examining, or
reviewing medical source opined that she had greater limitation in this domain.

In interacting with others, the claimant had a moderate limitation. She reported
that she lived with family, visited and socialized with other family members, left
her residence without accompaniment, and travelled to public locations such as
grocery stores (Id.). The claimant did not allege limitations in interacting or
getting along with others at the hearing. Mental status examinations describe a
pleasant, cooperative, alert, and fully oriented presentation without abnormalities
in mood, affect, appearance, speech, motor activity, eye contact, manner of
relating, insight, judgment, reasoning, perception, attention, concentration,
memory, cognitive functioning, or thought processes from the alleged onset date
through the date last insured. No treating, examining, or reviewing medical source
opined that she had greater limitation in this domain.

With regard to concentrating, persisting or maintaining pace, the claimant had a
moderate limitation. As discussed above, she cared for her personal needs, drove
a vehicle, left her residence without accompaniment, worked part-time as a
bartender and server, and performed household tasks such as painting, cleaning,
shopping, and preparing meals. Mental status examinations describe a pleasant,
cooperative, alert, and fully oriented presentation without abnormalities in mood,
affect, appearance, speech, motor activity, eye contact, manner of relating,
insight, judgment, reasoning, perception, attention, concentration, memory,
cognitive functioning, or thought processes from the alleged onset date through
the date last insured. No treating, examining, or reviewing medical source opined
that she had greater limitation in this domain.

As for adapting or managing oneself, the claimant had experienced a mild
limitation. She cared for her personal needs and helped maintain her residence.
She did not require psychiatric hospitalization or seek treatment with a
psychiatrist, psychologist, or counselor during the period at issue. There is no
evidence of self-injurious behavior or an inability to set realistic goals, make
plans independent of others, travel to unfamiliar places, or avoid normal hazards.

No treating, examining, or reviewing medical source opined that she had greater
limitation in this domain.

Because the claimant’s mental impairments did not cause at least two “marked”
limitations or one “extreme” limitation, the “paragraph B” criteria were not
satisfied.

The undersigned has also considered whether the “paragraph C” criteria were
satisfied. In this case, the evidence fails to establish the presence of the
“paragraph C” criteria. The medical evidence does not establish repeated episodes
of decompensation, a residual disease process that has resulted in such marginal
adjustment that even a minimal increase in mental demands or change in the
environment would be predicted to cause the claimant to decompensate, an
inability to function outside a highly supportive living arrangement, or a complete
inability to function independently outside the area of her home.

The limitations identified in the “paragraph B” criteria are not a residual
functional capacity assessment but are used to rate the severity of mental
impairments at steps 2 and 3 of the sequential evaluation process. The mental
residual functional capacity assessment used at steps 4 and 5 of the sequential
evaluation process requires a more detailed assessment of the areas of mental
functioning. The following residual functional capacity assessment reflects the
degree of limitation the undersigned has found in the “paragraph B” mental
function analysis.

5. 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 she
can occasionally climb ramps, stairs, ladders, ropes, and scaffolds; must
avoid all exposure to workplace hazards such as unprotected heights and
open moving machinery; is limited to simple tasks, simple instructions, and
simple decisions; cannot perform consistent rapid or production rate pace
work; can have occasional contact with coworkers, supervisors, and the
public; and is limited to few changes in work processes and locations.

In making this finding, the undersigned has considered all symptoms and the
extent to which these symptoms can reasonably be accepted as consistent with the
objective medical evidence and other evidence, based on the requirements of 20
CFR 404.1529 and SSR 16-3p. The undersigned also considered the medical
opinion(s) and prior administrative medical finding(s) in accordance with the
requirements of 20 CFR 404.1520c.

In considering the claimant’s symptoms, the undersigned must follow a two-step
process in which it must first be determined whether there is an underlying
medically determinable physical or mental impairment(s)--i.e., an impairment(s)

that can be shown by medically acceptable clinical or laboratory diagnostic
techniques--that could reasonably be expected to produce the
claimant’s pain or other symptoms.

Second, once an underlying physical or mental impairment(s) that could
reasonably be expected to produce the claimant’s pain or other symptoms has
been shown, the undersigned must evaluate the intensity, persistence, and limiting
effects of the claimant’s symptoms to determine the extent to which they limit the
claimant’s work-related activities. For this purpose, whenever statements about
the intensity, persistence, or functionally limiting effects of pain or other
symptoms are not substantiated by objective medical evidence, the undersigned
must consider other evidence in the record to determine if the claimant’s
symptoms limit the ability to do work related activities.

The claimant testified that, through the date last insured, she experienced
symptoms of ankle swelling, leg cramps, hot flashes, fatigue, back pain, and
impaired focus and memory secondary to cancer treatment. She stated that she
elevated her legs three times per week, napped for two hours per day, utilized a
cane for ambulation secondary to unsteadiness on her feet, and required
assistance from her husband for bathing during a period from 2016 until 2017.
She also testified to radiation chest burns that affected her ability to reach with the
left upper extremity. In addition to the impaired memory and focus, she alleged
mental health symptoms of depressed mood, feeling guilty, being easily
overwhelmed, and “bad” days once per month during which she isolated in her
bedroom.

After careful consideration of the evidence, the undersigned finds that the
claimant’s medically determinable impairments could reasonably be expected to
cause the alleged symptoms; however, the claimant’s statements concerning the
intensity, persistence and limiting effects of these symptoms are not entirely
consistent with the medical evidence and other evidence in the record for the
reasons explained in this decision.

In terms of the claimant’s physical allegations, the evidence of record fails to
support greater functional limitations than determined herein through the date last
insured. A routine mammogram found suspicious calcifications that were
suggestive of malignancy in November 2015 (Exhibit 1F). Supplemental
diagnostic studies confirmed left breast invasive ductal carcinoma with four
positive lymph nodes and negative margins in December 2015 (Id.). The
claimant underwent left breast mastectomy in January 2016 (Exhibit 3F). Follow-
up imaging studies are negative for metastatic disease in the chest, abdomen, and
pelvis (Id.). Postoperative treatment records document no subjective complaints
and examinations are entirely normal and found a healed mastectomy by February
2016 (Id. and 5F). The claimant underwent port placement and began
chemotherapy in February 2016 (Id.). She reported some initial nausea but

denied other symptoms and endorsed feeling well with normal activity levels
following her first chemotherapy cycle in March 2016 (Id.). The claimant also
reported that the nausea was relieved with Zofran following the second
chemotherapy round and denied adverse side effects in April 2016 (Id.). While the
claimant reported intermittent weakness and feeling tired, she denied excessive
malaise and fatigue following the 3rd chemotherapy cycle in April 2016 (Id.).
She completed her fourth round of chemotherapy and endorsed only fatigue and
generalized body aches for one to two days that was relieved with Aleve in May
2016 (Id.). She also reported that she currently feels well with stable energy levels
and appetite (Id.). The claimant subsequently began weekly Taxol therapy,
endorsed only minor myalgia that is relieved by Advil, and was found to be
tolerating said treatment very well without any difficulties in May 2016 (Id.). In
June 2016, the claimant reported only mild nausea and fatigue during the day of
treatment but stated that she remains very active and painted her living room (Id.).
She was assessed as doing very well without significant side effects (Id.). She
completed the Taxol therapy, which was tolerated without any problems in
August 2016 (Id.).

The claimant began radiation therapy, denied side effects, and reported that she is
doing very well with normal energy levels in September 2016 (Id.). A
preoperative evaluation reports no subjective complaints in November 2016
(Exhibit 1F). Secondary to a positive BRCA2 gene, the claimant underwent
elective hysterectomy and bilateral salpingo-oophorectomy in November
2016 (Id.). She reported only feeling kind of tired and fatigued with recent foot
swelling but indicated that these symptoms are not significant, and she is doing
well overall during a December 2016 follow-up examination (Exhibit 5F). While
workup revealed no right breast cancer, the claimant elected to undergo right
mastectomy due to the potential risks that are associated with the BRCA2 gene in
February 2017 (Exhibit 3F). In February 2017, she reported only some discomfort
in her ankles since returning to work and being on her feet all day but also
indicated that she is doing well overall (Exhibit 5F). The claimant was utilizing
Fosamax and denied adverse side effects at that time (Id.). The claimant endorsed
the onset of hot flashes and denied other symptoms in August 2017 (Id.). Upon
follow-up, the claimant reported that the hot flashes are not as prominent with the
use of Effexor in December 2017 (Id.). While she also reported some myalgias,
this is attributed to a lot of lifting and working with hands and arms as a
bartender in December 2017 (Exhibit 2F). The claimant next reported that that hot
flashes are manageable in April 2016 and only minor in severity in August 2018
(Exhibit 5F). She also reported that she is doing well overall through December
2018 (Id.). In February 2019, the claimant reported that her feet only slightly
swell after bartending on her feet for eleven hours at a time (Exhibit 2F). Most
recently, she reported that she is doing great and regularly walking for
exercise in June 2019, and endorsed good energy levels and appetite without
adverse hormonal therapy side effects in December 2019 (Exhibit 5F).
Longitudinally, oncology describes the claimant as doing well relative to the
cancer and treatment, and there is no evidence of recurrence or metastases from

February 2016 through December 2019 (Id.). The claimant also denied
respiratory, cardiovascular, gastrointestinal, and neurological symptoms,
including numbness, tingling, and burning, and oncology and primary care
examinations are wholly unremarkable, as they describe no edema and normal
respiratory, cardiovascular, gastrointestinal, genitourinary, musculoskeletal, and
neurological functioning to include gait, strength, sensations, reflexes, and range
of motion during this period (Id. and 2F). There is no evidence of incoordination,
imbalance, or unsteadiness, and no treating or examining medical source reports
the use of an assistive device for ambulation during the period under
consideration.

In considering the positive response to surgical intervention, diagnostic studies
that are negative for cancer recurrence and metastases, denial of significant
radiation, hormonal, bisphosphonate, and chemotherapy side effects, and
unremarkable clinical findings, the evidence off record fails to support the
severity of the claimant’s symptoms through the date last insured. These factors
are persuasive in finding that any reasonable limitation stemming from the cancer
and subsequent treatment is more than adequately accommodated within a light
residual functional capacity that involves occasional climbing and no exposure to
workplace hazards.

In considering the claimant's obesity, the undersigned finds no indication that this
condition, independently or in combination with co-existing impairments,
compromised her capacity to perform a range of light work. The claimant's
obesity did not affect her ability to use the upper extremities, get around on a
regular basis, engage in daily activities, or perform work activity in the past.
There also is no indication that the claimant's obesity has resulted in any other
clinical manifestations, including edema of the lower extremities, chest pain, or
shortness of breath. As discussed above, examinations show normal physical
functioning during the period at issue. Accordingly, the undersigned finds that
any reasonable limitation stemming from this condition is adequately
accommodated within the parameters of the residual functional capacity.

From a mental health standpoint, the evidence of record again fails to establish
greater functional limitations than determined herein. The record first reports mild
anxiety secondary to the cancer diagnosis in February 2016 (Exhibit 5F).
However, the claimant also reported that she is feeling well overall at that time
(Id.). The claimant next endorsed crying spells secondary to depression for which
Effexor was prescribed in August 2017 (Id.). She subsequently reported that the
depression improved with said medication through April 2018 and follow-up
oncology examinations are devoid of complaints related to the claimant’s mental
health through December 2019 (Id.). The claimant also reported that the
medication and working daily has helped the depression considerably in February
2019 (Exhibit 2F). Longitudinally, oncology and primary care examinations
describe a pleasant, cooperative, alert, and fully oriented presentation without

mental status abnormalities in mood, affect, appearance, speech, motor activity,
eye contact, manner of relating, insight, judgment, reasoning, perception,
attention, concentration, memory, cognitive functioning, or thought processes
from the alleged onset date through December 2019 (Id. and 5F). The claimant
did not require or pursue formal behavioral health treatment with a psychiatrist,
psychologist, or counselor. As discussed above, her activities of daily living were
intact from a mental health standpoint. In considering these factors most favorably
towards her, the undersigned has restricted the claimant to occupations that
involve simple tasks, simple instructions, simple decisions, occasional interaction
with others, few workplace changes, and no rapid or production rate pace
requirements thereby more than adequately accommodating any reasonable
limitation stemming from her mental impairments.

As for medical opinion(s) and prior administrative medical finding(s), the
undersigned cannot defer or give any specific evidentiary weight, including
controlling weight, to any prior administrative medical finding(s) or medical
opinion(s), including those from medical sources.

The undersigned has fully considered the medical opinions and prior
administrative medical findings as follows:

The undersigned is unpersuaded by the opinions of Dr. Hadeed and Ms. Lamary,
an oncologist and physician assistant, respectively, because they are inconsistent
with the oncology treatment records. Specifically, the opinions that the claimant
would be absent from work more than two days per month, off task more than
15% of a workday due to impaired attention and concentration, and need to take
extra breaks during the workday are inconsistent with the claimant’s subjective
reports that she is feeling well overall with normal activity and energy levels and
no significant cancer treatment side effects, and Dr. Hadeed’s assessments that
found her to be doing well overall from February 2016 through December 2019.
Additionally, physical and mental status examinations are wholly unremarkable
and show an awake, alert, and fully oriented presentation without clinical deficits
in attention or concentration during this period. Moreover, the medical source
statement does not supply objective signs or findings in support of the opinions;
Dr. Hadeed did not sign the medical source statement; and the medical record
documents no treatment with Ms. Lamary prior to the date last insured. As such,
Ms. Lamary’s and Dr. Hadeed’s August 2024 opinions are not an accurate
representation of the claimant’s level of functioning through June 2019, the date
last insured.

The undersigned is also unpersuaded by the State agency medical consultants’
opinions. While the longitudinal examinations, which found normal physical
functioning to include gait, strength, sensations, reflexes, range of motion, and
motor function, do not provide objective medical findings that would preclude
medium exertion work, the undersigned finds that the few complaints of fatigue

and body aches would reasonably restrict the claimant to light exertion lifting and
carrying.

The undersigned has also considered the June 2024 third-party statements from
Ms. Kendrew and McIlroy, the claimant’s former employers, and, to the extent
that they are consistent with the medical record, accepted them. However, their
statements do not establish that the claimant is disabled. They are not medical or
vocational professional and, as a lay witnesses, they are not competent to make
exacting observations as to the severity of the claimant's symptoms in relation to
her ability to perform all work activity in the national economy. More
importantly, the clinical and diagnostic medical evidence of record supports the
conclusions herein. For example, examinations show no lower extremity edema,
overt pain behaviors, acute distress, or deficits in grip strength or dexterity, which
fails to support the statements that the claimant’s feet swell with prolonged
standing, she experiences chronic pain, and she drops objects due to poor
grip. Thus, the undersigned does not find their statements to be particularly
persuasive because they are not entirely consistent with the preponderance of
evidence in this case, which directs a finding of not disabled through the date last
insured.

In sum, the above residual functional capacity assessment is supported by the
preponderance of medical and non-medical evidence of record, including the
claimant's course of treatment, response to treatment, and activities of daily
living. The claimant alleges limitations that would preclude the performance of
substantial gainful activity on a full-time basis. However, her allegations are not
entirely consistent with or supported by the medical and other evidence because a
review of the entire record fails to reasonably support the nature, intensity,
frequency, or duration of the limitations alleged by the claimant through the date
last insured.

6. The claimant has no past relevant work (20 CFR 404.1565).

7. The claimant was born on May 5, 1970 and was 49 years old, which is
defined as a younger individual age 18-49, on the date last insured (20 CFR
404.1563).

8. The claimant has at least a high school education (20 CFR 404.1564).

9. Transferability of job skills is not an issue because the claimant does not
have past relevant work (20 CFR 404.1568).

ECF 4-2, p. 25-32.

IV. ANALYSIS

A. Plaintiff’s Challenge to the ALJ’s RFC Determination
Plaintiff contends that the ALJ failed to support her residual functional capacity (“RFC”)
determination with substantial evidence, by specifically failing “to properly evaluate the
opinion[s] of Plaintiff’s treating providers, Dr. Hadeed and PA Lamary.” The Court disagrees.
First, as noted above, the ALJ stated:

“The undersigned is unpersuaded by the opinions of Dr. Hadeed and Ms.
Lamary, an oncologist and physician assistant, respectively, because they are
inconsistent with the oncology treatment records. Specifically, the opinions that
the claimant would be absent from work more than two days per month, off task
more than 15% of a workday due to impaired attention and concentration, and
need to take extra breaks during the workday are inconsistent with the claimant’s
subjective reports that she is feeling well overall with normal activity and energy
levels and no significant cancer treatment side effects, and Dr. Hadeed’s
assessments that found her to be doing well overall from February 2016 through
December 2019. Additionally, physical and mental status examinations are
wholly unremarkable and show an awake, alert, and fully oriented presentation
without clinical deficits in attention or concentration during this period.
Moreover, the medical source statement does not supply objective signs or
findings in support of the opinions; Dr. Hadeed did not sign the medical source
statement; and the medical record documents no treatment with Ms. Lamary prior
to the date last insured. As such, Ms. Lamary’s and Dr. Hadeed’s August 2024
opinions are not an accurate representation of the claimant’s level of functioning
through June 2019, the date last insured.

ECF 4-2, p. 31.
The ALJ, in addressing the opinions of Plaintiffs treating providers found that their
opinions did not match the objective findings found in Plaintiff’s treatment records. The ALJ
pointed to specifics where the opinions of the medical experts concerning Plaintiff’s alleged
impaired attention and concentration, and her alleged need to take extra breaks were wholly
inconsistent with the subjective reports delivered by Plaintiff herself an captured in the medical
record. Plaintiff reported feeling “well overall” and claimed to have “normal” energy and activity

levels with no significant cancer side effects. The ALJ had previously noted that some of the
side effects that Plaintiff did encounter, such as nausea, minor myalgia, and hot flashes and were
managed with medications, and at least one of which was nonprescription Advil. Plaintiff’s
providers found her mental status be “wholly unremarkable and show an awake, alert, and fully
oriented” individual “without clinical deficits in attention or concentration[,]” thus providing
additional evidence in support of the ALJ’s determination related to the RFC.
Next, the ALJ also considered the state agency’s medical consultants but discounted
those opinions as well. The opinions of the state agency’s medical consultants concluded that
Plaintiff could perform medium duty work. The ALJ found that these opinions were also not
supported by the Plaintiff’s medical record as a whole, specifically noting that Plaintiff possessed
some restrictive work abilities and thus, was able to perform light work, but not the medium
level that the state agency providers recommended.
Finally, the ALJ did consider and properly discounted the lay opinions of Plaintiff’s
former employers. As noted by the ALJ:
“Ms. Kendrew and McIlroy, the claimant’s former employers . . . do not establish
that the claimant is disabled. They are not medical or vocational professional and,
as a lay witnesses, they are not competent to make exacting observations as to the
severity of the claimant’s symptoms in relation to her ability to perform all work
activity in the national economy. More importantly, the clinical and diagnostic
medical evidence of record supports the conclusions herein. For example,
examinations show no lower extremity edema, overt pain behaviors, acute
distress, or deficits in grip strength or dexterity, which fails to support the
statements that the claimant’s feet swell with prolonged standing, she experiences
chronic pain, and she drops objects due to poor grip. Thus, the undersigned does
not find their statements to be particularly persuasive because they are not entirely
consistent with the preponderance of evidence in this case, which directs a finding
of not disabled through the date last insured.

ECF 4-2, p.31.

Based on the Court’s review of the evidence in this case, the Court finds that the ALJ’s
RFC determination was based on substantial evidence of record and therefore, the Court will
deny the Plaintiff’s motion in this regard.
B. Plaintiff’s Challenge to ALJ’s evaluation of Plaintiff’s subjective complaints
Plaintiff, noting that the ALJ had to complete a two-step process to evaluate her
subjective complaints, has also argued that the ALJ did not do so. Again, the Court disagrees
with Plaintiff.
The ALJ stated:
In considering the claimant’s symptoms, the undersigned must follow a two-step
process in which it must first be determined whether there is an underlying
medically determinable physical or mental impairment(s)--i.e., an impairment(s)
that can be shown by medically acceptable clinical or laboratory diagnostic
techniques--that could reasonably be expected to produce the
claimant’s pain or other symptoms.

ECF 4-1, p. 28.
Immediately following these statements, the ALJ carefully laid out all of Plaintiff’s
cancer treatments quoting from the medical records extensively in an effort to demonstrate the
incongruent nature of Plaintiff’s physical condition as captured by her medical providers at the
time she underwent treatment and her own claims of disability. The Court also notes that
Plaintiff’s subjective complaints, alone, can never establish liability and the ALJ would have had
to at least reference objective clinical signs and lab results which would have supported
Plaintiff’s subjective complaints. 20 C.F.R. 404.1529(b) and (c)(1)-(3). Because no such findings
in the medical record as a whole support Plaintiff’s complaints and because the ALJ’s
determination demonstrates (as quoted above) that she did in fact consider Plaintiff’s complaints,
the Court will deny the Plaintiff’s motion in this regard also.

V. CONCLUSION
AND NOW this, 15th day of May, 2026, based on the foregoing law and authority, the
Court DENIES Plaintiff’s motion for summary judgment (ECF 11).
s/ Arthur J. Schwab
Arthur J. Schwab
United States District Judge

cc: All Registered ECF Counsel and Parties

Passage view · GavelSight