REPORT AND RECOMMENDATION

MARTIN C. CARLSON, Magistrate Judge.

I. Introduction

In this Social Security Appeal, we are called upon to review the sufficiency of an Administrative Law Judge's (ALJ) assessment of the sole medical opinion in the record, that of a treating physician. We are asked to conduct this evaluation in the case of Trevor Hynd ("Mr. Hynd"), an individual who suffers from degenerative disc disease and fibromyalgia. (Tr. 31.) We undertake this review in a factual context in which the ALJ explained that the treating source's opinion was "given weight to the extent it is consistent with the objective radiographic and monthly examination findings." (Tr. 40.) While it is not entirely clear from this cursory description what the basis was for the ALJ's decision to largely reject the treating source's opinion, the ALJ's assertions that a finding of disability was "not supported by the record as a whole" appears to be at odds in some material ways with the factual record, which documents a prolonged history of progressive pain associated with these impairments. Thus, in the instant case we are presented with an ALJ's decision to reject a treating source opinion which appears to be the only medical opinion on the record, and was the sole medical opinion considered by the ALJ. Since the medical record provides support for the treating source's opinion, and the ALJ's decision to discount this opinion in the absence of any other medical source opinion is not sufficiently supported, it is recommended that this case be remanded to the Commissioner for further proceedings.

II. Statement of Facts and of the Case

Mr. Hynd's health ailments related to his disability claims began in late 2009. (Tr. 296.) Mr. Hynd was uncertain what initially caused his back pain, and he reported that the pain originated in his back, shoulder, and neck and radiates into his arms and legs. (Id.) On July 17, 2013, Mr. Hynd protectively filed an application for disability benefits under Title II of the Social Security Act. (Tr. 215-216.) Two months later, Mr. Hynd filed an application for supplemental security income benefits under Title XVI of the Social Security Act. (Tr. 217-225.) Mr. Hynd claimed that he has been disabled since March 15, 2013, because of degenerative disc disease and fibromyalgia. (Tr. 268; 271.) At the time of Mr. Hynd's applications, and the onset of his alleged disability, he was in his early 30's and was considered a "younger individual" according to the regulations promulgated under the authority of the Act.2 (Tr. 268.) Mr. Hynd is a high school graduate and attended one year of college. (Tr. 272.) His work history report includes employment spanning from 2001 through 2013, in which he worked in various positions in the retail sector, as well as positions in food service, telemarketing, and the military. (Tr. 300.)

Mr. Hynd's disability applications were initially denied on October 17, 2013, (Tr. 102-110) and November 1, 2013, he sought a hearing to contest the denials. (Tr. 114-116.) On June 6, 2015, the ALJ conducted a hearing considering Mr. Hynd's disability applications. (Tr. 48-81.) At this hearing, the ALJ heard testimony from Mr. Hynd, Mr. Hynd's wife, and Michael Kibbler, an impartial vocational expert. (Id.) Mr. Hynd testified that he is disabled because of his pain condition. (Tr. 54.) He explained that his daily pain limits almost all activity, and he cannot keep a reliable schedule because the pain is unpredictable. (Id.) Mr. Hynd reported that approximately two to three times per week, his pain is so unbearable that he cannot get out of bed. (Tr. 55.) He explained that there are times when he awakens with pain for no particular reason. (Tr. 67.) Mr. Hynd reported that he can only sit in one position for up to an hour, because sitting too long precipitates the pain and causes pain and numbness throughout his legs. (Tr. 59-60.) He explained that he can comfortably lift up to five pounds only. (Tr. 60.)

The ALJ also received and reviewed an abundance of medical records from multiple medical sources (Tr. 377-724), and had the benefit of an opinion from treating physician Dr. Upadhyay. (Tr. 717-724.) Dr. Upadhyay concluded that Mr. Hynd's impairments restrict him from prolonged sitting, standing, and walking, as well as restrict him from lifting, pushing, and carrying. (Tr. 717.) Dr. Upadhyay opined that Mr. Hynd's condition will slowly worsen as he gets older. (Id.) Dr. Upadhyay determined that Mr. Hynd can: stand/walk for one half hour at a time, and for a total of two hours in an eight-hour work day; sit for one hour at a time, and for a total of five hours in an eight-hour work day; and drive a vehicle for up to one half hour at a time, and for a total of one hour in an eight-hour work day. (Tr. 719-720.) Dr. Upadhyay assessed that Mr. Hynd can lift/carry up to ten pounds occasionally. (Id.) Ultimately, Dr. Upadhyay opined that Mr. Hynd is limited to less than sedentary work and is not physically capable of working an eight-hour work day five days per week. (Tr. 723; 724.)

Following the hearing, on August 27, 2015, the ALJ issued a decision denying Mr. Hynd's applications for disability benefits. (Tr. 26-47.) In this decision, the ALJ first found that Mr. Hynd met the insured requirements of the Act through December 31, 2017. (Tr. 31.) At Step 2 of the five-step sequential analysis process that applies to Social Security disability claims, the ALJ concluded that Mr. Hynd experienced the following severe impairments: degenerative disc disease and fibromyalgia. (Id.) At Step 3 of this sequential analysis, the ALJ concluded that none of Mr. Hynd's impairments met a listing that would define him as per se disabled. (Tr. 32.)

Before considering Step 4, the ALJ fashioned Mr. Hynd's residual functional capacity. The ALJ concluded that Mr. Hynd is able to perform a range of sedentary work with limitations. (Tr. 33.) Specifically, the ALJ determined that Mr. Hynd can only lift up to ten pounds occasionally, stand and/or walk up to two hours in an eight-hour work day, sit up to six hours in an eight-hour work day, and sit and stand every hour at will. (Id.) The ALJ added the limitation that the work should be routine and repetitive and performed in an environment free of fast-paced production requirements. (Id.)

In reaching this conclusion, the ALJ partially discounted Mr. Hynd's statements concerning the intensity, persistence, and limiting effects of his symptoms, noting that his conditions have not warranted surgery, he has no problems with sleep despite his significant levels of pain, and pain medication and sitting alleviated his pain. (Tr. 34; 39.) The ALJ then canvassed the clinical, diagnostic, and medical opinion evidence before concluding that Mr. Hynd retained the residual functional capacity to perform a range of sedentary work, with the above discussed limitations. (Id.) Having made these findings, the ALJ concluded, consistent with the testimony of the vocational expert that Mr. Hynd could return to his past relevant work as an order clerk and telephone solicitor. (Tr. 41.)

The ALJ moved on to Step Five, though not necessary, noting that she made these findings in the alternative. (Tr. 41.) The ALJ found that based on the above discussed RFC, and considering Mr. Hynd's age, education, work experience, and residual functional capacity, jobs existed in significant numbers in the national economy that Mr. Hynd could perform. (Id.) The ALJ explained that if Mr. Hynd had the RFC to perform the full range of sedentary work, a finding of "not disabled" would be directed by Medical-Vocational Rule 201.28, but because Mr. Hynd is impeded by additional limitations, the ALJ relied upon testimony from the vocational expert to determine if these limitations eroded the unskilled sedentary occupational base. (Tr. 42.) Based upon the vocational expert's testimony, the ALJ determined Mr. Hynd is able to perform the following unskilled in nature and sedentary exertion occupations: table worker3 and final assembler.4 (Id.) The ALJ determined that pursuant to the guidelines set forth in SSR 00-4p, the vocational expert's testimony was consistent with the information published in the DOT. (Id.) However, the ALJ noted that the DOT does not address the sit/stand option, and that the vocational expert identified jobs allowing that accommodation based upon his experience and observations working in the field. (Id.) Ultimately, the ALJ found Mr. Hynd not disabled. (Id.)

Having exhausted his administrative remedies with respect to this adverse decision, Mr. Hynd filed the instant appeal. (Doc. 1.) On appeal, Mr. Hynd argues that the ALJ's decision is not supported by substantial evidence, and is arbitrary and capricious. (Doc. 1 p. 3.) He alleges that the ALJ applied incorrect legal standards. (Id.) This case is fully briefed and is now ripe for resolution.

III. Discussion

A. Substantial Evidence Review — the Role of this Court

When reviewing the Commissioner's final decision denying a claimant's application for benefits, this Court's review is limited to the question of whether the findings of the final decision-maker are supported by substantial evidence in the record. See 42 U.S.C. §405(g); Johnson v. Comm'r. of Soc. Sec., 529 F.3d 198, 200 (3d Cir. 2008); Ficca v. Astrue, 901 F.Supp.2d 533, 536 (M.D.Pa. 2012). Substantial evidence "does not mean a large or considerable amount of evidence, but rather such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Pierce v. Underwood, 487 U.S. 552, 565 (1988). Substantial evidence is less than a preponderance of the evidence but more than a mere scintilla. Richardson v. Perales, 402 U.S. 389, 401 (1971). A single piece of evidence is not substantial evidence if the ALJ ignores countervailing evidence or fails to resolve a conflict created by the evidence. Mason v. Shalala, 994 F.2d 1058, 1064 (3d Cir. 1993). But in an adequately developed factual record, substantial evidence may be "something less than the weight of the evidence, and the possibility of drawing two inconsistent conclusions from the evidence does not prevent [the ALJ's decision] from being supported by substantial evidence." Consolo v. Fed. Maritime Comm'n, 383 U.S. 607, 620 (1966). "In determining if the Commissioner's decision is supported by substantial evidence the court must scrutinize the record as a whole." Leslie v. Barnhart, 304 F.Supp.2d 623, 627 (M.D.Pa. 2003). The question before this Court, therefore, is not whether Mr. Hynd is disabled, but whether the Commissioner's finding that he is not disabled is supported by substantial evidence and was reached based upon a correct application of the relevant law. See Arnold v. Colvin, No. 3:12-CV-02417, 2014 WL 940205, at *1 (M.D.Pa. Mar. 11, 2014)("[I]t has been held that an ALJ's errors of law denote a lack of substantial evidence.")(alterations omitted); Burton v. Schweiker, 512 F.Supp. 913, 914 (W.D.Pa. 1981)("The Secretary's determination as to the status of a claim requires the correct application of the law to the facts."); see also Wright v. Sullivan, 900 F.2d 675, 678 (3d Cir. 1990)(noting that the scope of review on legal matters is plenary); Ficca, 901 F. Supp.2d at 536 ("[T]he court has plenary review of all legal issues....").

B. Initial Burdens of Proof, Persuasion, and Articulation for the ALJ

To receive benefits under the Social Security Act by reason of disability, a claimant must demonstrate an inability 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 12 months." 42 U.S.C. §423(d)(1)(A); 42 U.S.C. §1382c(a)(3)(A); see also 20 C.F.R. §§404.1505(a), 416.905(a). To satisfy this requirement, a claimant must have a severe physical or mental impairment that makes it impossible to do his or her previous work or any other substantial gainful activity that exists in the national economy. 42 U.S.C. §423(d)(2)(A); 42 U.S.C. §1382c(a)(3)(B); 20 C.F.R. §§404.1505(a), 416.905(a). To receive benefits under Title II of the Social Security Act, a claimant must show that he or she contributed to the insurance program, is under retirement age, and became disabled prior to the date on which he or she was last insured. 42 U.S.C. §423(a); 20 C.F.R. §404.131(a).

In making this determination at the administrative level, the ALJ follows a five-step sequential evaluation process. 20 C.F.R. §§404.1520(a), 416.920(a). Under this process, the ALJ must sequentially determine: (1) whether the claimant is engaged in substantial gainful activity; (2) whether the claimant has a severe impairment; (3) whether the claimant's impairment meets or equals a listed impairment; (4) whether the claimant is able to do his or her past relevant work; and (5) whether the claimant is able to do any other work, considering his or her age, education, work experience and residual functional capacity ("RFC"). 20 C.F.R. §§404.1520(a)(4), 416.920(a)(4).

Between Steps 3 and 4, the ALJ must also assess a claimant's RFC. RFC is defined as "that which an individual is still able to do despite the limitations caused by his or her impairment(s)." Burnett v. Comm'r of Soc. Sec., 220 F.3d 112, 121 (3d Cir. 2000) (citations omitted); see also 20 C.F.R. §§404.1520(e), 404.1545(a)(1), 416.920(e), 416.945(a)(1). In making this assessment, the ALJ considers all of the claimant's medically determinable impairments, including any non-severe impairments identified by the ALJ at step two of his or her analysis. 20 C.F.R. §§404.1545(a)(2), 416.945(a)(2).

There is an undeniable medical aspect to an RFC determination, since that determination entails an assessment of what work the claimant can do given the physical limitations that the claimant experiences. Yet, when considering the role and necessity of medical opinion evidence in making this determination, courts have followed several different paths. Some courts emphasize the importance of medical opinion support for an RFC determination and have suggested that "[r]arely can a decision be made regarding a claimant's residual functional capacity without an assessment from a physician regarding the functional abilities of the claimant." Biller v. Acting Comm'r of Soc. Sec., 962 F.Supp.2d 761, 778-79 (W.D. Pa. 2013) (quoting Gormont v. Astrue, Civ. No. 11-2145, 2013 WL 791455 at *7 (M.D. Pa. Mar. 4, 2013)). In other instances, it has been held that: "There is no legal requirement that a physician have made the particular findings that an ALJ adopts in the course of determining an RFC." Titterington v. Barnhart, 174 F. App'x 6, 11 (3d Cir. 2006). Further, courts have held in cases where there is no evidence of any credible medical opinion supporting a claimant's allegations of disability that "the proposition that an ALJ must always base his RFC on a medical opinion from a physician is misguided." Cummings v. Colvin, 129 F.Supp.3d 209, 214-15 (W.D. Pa. 2015).

These seemingly discordant legal propositions can be reconciled by evaluation of the factual context of these decisions. Those cases which emphasize the importance of medical opinion support for an RFC assessment typically arise in the factual setting where a medical source has opined regarding limitations which would support a disability claim, but an ALJ has rejected the medical opinion which supported a disability determination based upon a lay assessment of other evidence. Thus, when an ALJ is saying that a claimant can do more than the medical source opinion states, courts exercise great caution and suggest that only rarely can an ALJ unilaterally impose an RFC on a claimant that is less restrictive than the RFC found by the medical professional. Construed in this light, these cases simply restate the commonplace idea that medical opinions are entitled to careful consideration when making a disability determination, particularly when those opinions support a finding of disability.

In contrast, when an ALJ is relying upon other evidence to conclude that the claimant can do less than a medical source opined, or when an ALJ fashions an RFC determination in the absence of any medical opinion evidence, courts have adopted a more pragmatic view and have sustained the ALJ's exercise of independent judgment based upon all of the facts and evidence. See Titterington v. Barnhart, 174 F. App'x 6, 11 (3d Cir. 2006); Cummings v. Colvin, 129 F.Supp.3d 209, 214-15 (W.D. Pa. 2015). In either event, once the ALJ has made this determination, our review of the ALJ's assessment of the plaintiff's RFC is deferential, and that RFC assessment will not be set aside if it is supported by substantial evidence. Burns v. Barnhart, 312 F.3d 113, 129 (3d Cir. 2002); see, e.g., Metzger v. Berryhill, No. 3:16-CV-1929, 2017 WL 1483328, at *5 (M.D. Pa. Mar. 29, 2017), report and recommendation adopted sub nom. Metzgar v. Colvin, No. 3:16-CV-1929, 2017 WL 1479426 (M.D. Pa. Apr. 21, 2017); Rathbun v. Berryhill, No. 3:17-CV-00301, 2018 WL 1514383, at *6 (M.D. Pa. Mar. 12, 2018), report and recommendation adopted, No. 3:17-CV-301, 2018 WL 1479366 (M.D. Pa. Mar. 27, 2018).

At Steps 1 through 4, the claimant bears the initial burden of demonstrating the existence of a medically determinable impairment that prevents him or her in engaging in any of his or her past relevant work. 42 U.S.C. §423(d)(5); 42 U.S.C. §1382c(a)(3)(H)(i)(incorporating 42 U.S.C. §423(d)(5) by reference); 20 C.F.R. §§404.1512, 416.912;5 Mason, 994 F.2d at 1064.

Once this burden has been met by the claimant, it shifts to the Commissioner at Step 5 to show that jobs exist in significant number in the national economy that the claimant could perform that are consistent with the claimant's age, education, work experience and RFC. 20 C.F.R. §§404.1512(f), 416.912(f); Mason, 994 F.2d at 1064.

The ALJ's disability determination must also meet certain basic substantive requisites. Most significant among these legal benchmarks is a requirement that the ALJ adequately explain the legal and factual basis for this disability determination. Thus, in order to facilitate review of the decision under the substantial evidence standard, the ALJ's decision must be accompanied by "a clear and satisfactory explication of the basis on which it rests." Cotter v. Harris, 642 F.2d 700, 704 (3d Cir. 1981). Conflicts in the evidence must be resolved and the ALJ must indicate which evidence was accepted, which evidence was rejected, and the reasons for rejecting certain evidence. Id. at 706-707. In addition, "[t]he ALJ must indicate in his decision which evidence he has rejected and which he is relying on as the basis for his finding." Schaudeck v. Comm'r of Soc. Sec., 181 F.3d 429, 433 (3d Cir. 1999).

C. Legal Benchmarks for the ALJ's Assessment of Medical Opinion Evidence

In deciding what weight to accord to competing medical opinions, the ALJ is guided by factors outlined in 20 C.F.R. §§ 404.1527(c) and 416.927(c). "The regulations provide progressively more rigorous tests for weighing opinions as the ties between the source of the opinion and the individual become weaker." SSR 96-6p, 1996 WL 374180 at *2. Generally, more weight will be given to a source who has examined the claimant than to a source who has not. 20 C.F.R. § 404.1527(c)(1); 20 C.F.R. § 416.927(c)(1). Treating sources have the closest ties to the claimant, and therefore their opinions generally entitled to more weight. See 20 C.F.R. §§ 404.1527(c)(2), 416.927(c)(2)("Generally, we give more weight to opinions from your treating sources..."); 20 C.F.R. §§ 404.1502 and 416.902(defining treating source).

"A cardinal principle guiding disability eligibility determinations is that the ALJ accord treating physicians' reports great weight, especially when their opinions reflect expert judgment based on continuing observation of the patient's condition over a prolonged period of time." Morales v. Apfel, 225 F.3d 310, 317 (3d Cir. 2000)(citations omitted); see also Brownawell v. Comm'r of Soc. Sec., 554 F.3d 352, 355 (3d Cir. 2008). In choosing to reject the treating physician's assessment, an ALJ may not make "speculative inferences from medical reports and may reject a treating physician's opinion outright only on the basis of contradictory medical evidence and not due to his or her own credibility judgments, speculation, or lay opinion." Apfel, 225 F.3d at 317. Thus, an ALJ may not unilaterally reject a treating source's opinion, and substitute the judge's own lay judgment for that medical opinion. Instead, the ALJ typically may only discount such an opinion when it conflicts with other objective tests or examination results. See Johnson v. Comm'r of Soc. Sec., 529 F.3d 198, 202-03 (3d Cir. 2008). Likewise, an ALJ may conclude that discrepancies between the treating source's medical opinion, and the doctor's actual treatment notes, justifies giving a treating source opinion little weight in a disability analysis. Torres v. Barnhart, 139 Fed.Appx. 411, 415 (3d Cir. 2005).

Where no medical source opinion is entitled to controlling weight, the Commissioner's regulations direct the ALJ to consider the following factors, where applicable, in deciding the weight given to any non-controlling medical opinions: length of the treatment relationship and frequency of examination; nature and extent of the treatment relationship; the extent to which the source presented relevant evidence to support his or her medical opinion, and the extent to which the basis for the source's conclusions were explained; the extent to which the source's opinion is consistent with the record as a whole; whether the source is a specialist; and, any other factors brought to the ALJ's attention. 20 C.F.R. §§ 404.1527(c), 416.927(c). Further, although treating and examining physician opinions often deserve more weight than the opinions of doctors who review records, see, e.g., 20 C.F.R. § 404.1527(d)(1)-(2); see also 20 C.F.R. § 416.927(c)(2), "[t]he law is clear... that the opinion of a treating physician does not bind the ALJ on the issue of functional capacity." Brown v. Astrue, 649 F.3d 193, 197 n. 2 (3d Cir. 2011). Moreover, 20 C.F.R. §§ 404.1527(c)(2) and 416.927(c)(2) require that the Commissioner "will always give good reasons in [her] notice of determination or decision for the weight [she] gives to [a claimant's] treating source's opinion." "An ALJ `may not reject [a physician's] findings unless he first weighs them against other relevant evidence and explains why certain evidence has been accepted and why other evidence has been rejected.'" Mason v. Shalala, 994 F.2d 1058, 1067 (3d Cir. 1993)(quoting Kent v. Schweiker, 710 F.2d 110, 115 n. 5 (3d Cir. 1983)).

In making this assessment of medical evidence:

Durden v. Colvin, 191 F.Supp.3d 429, 455 (M.D. Pa. 2016).

It is equally clear, however, that an ALJ may not unilaterally reject all medical opinions in favor of the ALJ's own subjective impressions. Durden v. Colvin, 191 F.Supp.3d 429, 455 (M.D. Pa. 2016) (citing Thanh Tam Vo v. Colvin, No. 1:14-CV-00541-GBC, 2015 WL 5514981, at *4 (M.D. Pa. Sept. 15, 2015) (remanding where ALJ completely rejected all medical opinions, even the one that supported the ALJ's RFC)). Thus,

Burns v. Colvin, 156 F.Supp.3d 579, 583 (M.D. Pa. 2016).

In short, "rarely can a decision be made regarding a claimant's residual functional capacity without an assessment from a physician regarding the functional abilities of the claimant." Ennis v. Astrue, No. 4:11-CV-01788, 2013 WL 74375, at *6 (M.D. Pa. Jan. 4, 2013) (citing Doak v. Heckler, 790 F.2d 26, 29 (3d Cir. 1986) ("No physician suggested that the activity Doak could perform was consistent with the definition of light work set forth in the regulations, and therefore the ALJ's conclusion that he could is not supported by substantial evidence.")); see Case v. Colvin, No. 3:16-CV-1782, 2017 WL 3394152, at *9 (M.D. Pa. Aug. 8, 2017).

D. The ALJ's Decision in this Case is Not Supported by Substantial Evidence

Judged against this standard of review, we find that the ALJ's decision in Hynd's case is not adequately explained or supported by the evidence, and remand is appropriate here to allow for further consideration of the treating source opinion. The sole medical opinion in the record is authored by Dr. Upadhyay, Mr. Hynd's treating physician. Dr. Upadhyay authored a six-page medical opinion titled "Job Capabilities and Restrictions," which included a one-page explanation in support of his findings. (Tr. 717-724.) Dr. Upadhyay explained that he has treated Mr. Hynd for the past two years, and his initial impression was that Mr. Hynd suffered from peripheral neuropathy, as well as degenerative lumbar spine disease. (Tr. 717.) Dr. Upadhyay noted that Mr. Hynd's medication greatly affects his ability to work, due to the severe cognitive sedation the medicine causes. (Tr. 724.) Dr. Upadhyay reported that Mr. Hynd's imaging studies demonstrate severe thoracic and lumbar degenerative disc disease. (Tr. 717.) Dr. Upadhyay opined that Mr. Hynd's orthopedic impairments render his occupational functionality below the sedentary level,6 and his condition is expected to slowly worsen as he ages. (Id.) According to Dr. Upadhyay, in an eight-hour work day, Mr. Hynd is limited to standing and walking for one half hour at a time, for a total of two hours, and sitting for one hour at a time, for a total of five hours. (Tr. 719-720.) Dr. Upadhyay also determined that Mr. Hynd is limited to occasionally lifting and carrying no more than ten pounds. (Tr. 720.)

In her decision, the ALJ canvassed the record and provided a lengthy discussion as to Mr. Hynd's treatment records; but she ultimately dismissed Dr. Upadhyay's opinion. However, Dr. Upadhyay's medical opinion was confirmed and corroborated in a number of ways by the evidence that was before the ALJ. Objective medical evidence, including x-ray reports, MRI reports, and treatment notes from other physicians substantiated that Mr. Hynd suffers from an array of impairments. Mr. Hynd had a documented history of back problems, well before his alleged onset date of March 15, 2013. In November of 2009, Mr. Hynd was rear-ended by a truck on Interstate 95. (Tr. 541.) He reported that within ten minutes of the accident, his neck and back pain intensified, and he was taken to a local hospital and evaluated. (Id.) One week after the accident, Mr. Hynd presented to his physician, complaining of severe pain in his neck and back. (Id.) An examination revealed cervical spine abnormalities, as well as muscle spasms in his spine, and a positive straight-leg raising test. (Tr. 542.) An x-ray displayed Schmorl Nodes at L2-L3 and resorbed limbus vertebral body at L2.7 (Tr. 548.) Two months later, Mr. Hynd underwent another x-ray, which revealed multilevel Schmorl's nodes and multilevel mild spondyloarthropathy. (Tr. 564-565.) Mr. Hynd's rheumatologic work up indicated a positive reading for HLA-B27.8 (Tr. 550.) A November 2011 MRI revealed mild degenerative disc disease at C5-6 and C6-7. (Tr. 516.) In December of 2012, Mr. Hynd was referred to a pain management clinic. (Tr. 510.) At the initial consultation, the attending physician examined Mr. Hynd and assessed that Mr. Hynd suffered from multifocal spondylosis, epiphysis of the vertebrae, and degenerative disc disease. (Tr. 512.) Mr. Hynd continued ongoing treatment and testing for his back pain.

Three months after Mr. Hynd's alleged onset disability date, Mr. Hynd was referred to Dr. Upadhyay for pain management in connection with his back pain. (Tr. 624.) After an examination, Dr. Upadhyay noted that Mr. Hynd's severe neck and back pain with dysesthesias was a concern. (Tr. 626.) Dr. Upadhyay ordered a neurology consultation to further assess for peripheral neuropathy and motor neuron disease. (Id.) Mr. Hynd's neurological consultation in August of 2013 revealed no finding of peripheral neuropathy; rather, he was diagnosed with secondary fibromyalgia. (Tr. 620-621.) Upon examination, Mr. Hynd demonstrated tenderness in his upper extremity region, hip pain with straight leg raising, and a marked reduction lumbar flexibility in all directions. (Tr. 620.)

Mr. Hynd continued to see a variety of specialists in an effort to reveal the etiology of his back pain. In March of 2014, Mr. Hynd underwent a rheumatology consultation. (Tr. 651.) The rheumatologist opined that Mr. Hynd does not suffer from inflammatory arthropathy, and his clinical picture is not compatible with ankylosing spondylitis. (Tr. 651.) The rheumatologist ordered x-rays of the sacroiliac joints and the lumbar spine. (Tr. 652.) In April of 2015, Mr. Hynd underwent a physiatrist consultation. (Tr. 656.) The physiatrist assessed Mr. Hynd's previous MRIs and observed that the MRIs showed multilevel degenerative changes in both the thoracic and lumbar spine. (Tr. 658.) An examination revealed that Mr. Hynd's lumbar lordosis was markedly increased, and his range of motion caused pain in multiple areas. (Tr. 663-664.) The physiatrist observed that Mr. Hynd's spine has a superior endplate deformity of L2, L3, and possibly L1. (Tr. 665.)

Mr. Hynd continued regular pain management with Dr. Upadhyay, with his last documented visit on May 5, 2015. (Tr. 671.) Dr. Upadhyay noted that a recent MRI of Mr. Hynd's spine revealed significant discogenic changes in the dorsal and lumbar spine. (Id.) Dr. Upadhyay recommended that diagnostic steroid injections could be beneficial, as well as the placement of a spinal cord stimulator. (Tr. 672.)

In addition to the objective medical evidence, Mr. Hynd reported that bending, reaching, walking, running, driving, and standing too long causes him pain. (Tr. 296.) Mr. Hynd testified that he needs to recline at least two to three times per week for three to four hours at a time. (Tr. 63-64.) At Mr. Hynd's last documented doctor's appointment with Dr. Upadhyay, he reported pain in his back and neck, aggravated by standing and walking and alleviated by medication and lying down. (Tr. 671.) In a Third-Party Function Report, Mr. Hynd's wife acknowledged that he cannot lift more than ten pounds without great pain, and he can only walk 100-200 yards before discomfort and pain. (Tr. 285.)

Despite the body of evidence supporting Dr. Upadhyay's opinion, the ALJ seemingly rejected this treating source opinion in a conclusory fashion, stating that one statement of Dr. Upadhyay's opinion "is of little probative value" and that the remainder of Dr. Upadhyay's opinion "is given weight to the extent it is consistent with the radiographic and monthly examination findings." (Tr. 40.)

At the outset, we note that this language in seemingly discounting Dr. Upadhyay's opinion lacks the required clarity that is called for when addressing medical opinions, as the ALJ did not articulate what weight was given to Dr. Upadhyay's opinion.9 Rather, the ALJ explained that Dr. Upadhyay's opinion is given weight to the extent it is consistent with radiographic and monthly examination findings. The regulations call for the ALJ to provide good reasons for discounting treating physicians' opinions, reasons that are "sufficiently specific to make clear to any subsequent reviewers the weight the adjudicator gave to the treating source's medical opinion and the reasons for that weight." See SSR 96-2p, 1996 WL 374188 at *5. From the ALJ's narrative, we are unable to discern precisely what weight the ALJ afforded Dr. Upadhyay's opinion, and whether or not the ALJ gave Dr. Upadhyay's opinion controlling weight.

Furthermore, the ALJ's proffered justification for appearing to have largely discounted Dr. Upadhyay's opinion cannot withstand careful scrutiny. The ALJ's assertion that the restrictions Dr. Upadhyay assessed for Mr. Hynd are not supported by the record as a whole does not appear to fully take into account the clinical test results and treatment notes from the various physicians that treated Mr. Hynd. Since "an ALJ may not make `speculative inferences from medical reports and may reject a treating physician's opinion outright only on the basis of contradictory medical evidence and not due to his or her own credibility judgments, speculation, or lay opinion.' Morales v. Apfel, supra at 317," Morder v. Colvin, No. 3:16-CV-213, 2016 WL 6191892, at *10 (M.D. Pa. Oct. 24, 2016), the passing assertion that Dr. Upadyay's opinion is not supported by the record as a whole—an assertion which actually seems to be contradicted, at least in part, by the medical record—does not justify discounting the treating source opinion in this case.

Moreover, the ALJ does not cite to any medical source that contradicts Dr. Upadhyay's opinion. The record contains no assessment of Mr. Hynd's physical limitations by any other doctor or by any state agency medical consultant. The ALJ did not cite other opinions or evidence directly contradicting Dr. Upadhyay's opinion, because no such directly countervailing existed. Instead, the ALJ's consideration of this treating source medical opinion approached something which the law prohibits-the substitution of the ALJ's medical judgments for those of the treating physician. The ALJ's disregard of Dr. Upadhyay's opinion, the sole medical opinion in this case, did not adequately address the significant weight that this opinion is entitled to receive.

Finally, the Third Circuit Court of Appeals has acknowledged that "[c]omplaints of disabling back pain are the most difficult types of claims to resolve with any degree of certainty." Taybron v. Harris, 667 F.2d 412, 415 (3d Cir.1981) (citations omitted). Disability claims based on pain are difficult to resolve because proof of pain is often made by means of subjective evidence. Id. In this case, Mr. Hynd has provided objective and subject evidence regarding the extent of his back pain. In view of the importance of credibility in cases of alleged disability due to back pain, the assessment of Mr. Hynd's treating physician, and the lack of conflicting opinion evidence, we are unable to say that the ALJ's determination that Mr. Hynd is not disabled is based on substantial evidence.

Guidance from the Social Security Administration provides that countervailing non-medical evidence can in some cases be substantial enough to warrant rejecting a treating source opinion, but the SSA "would expect it to be an extremely rare occurrence....For example, an opinion from a treating source about what a claimant can still do which would seem to be well-supported by the objective findings would not be entitled to controlling weight if there was other substantial evidence that the claimant engaged in activities that were inconsistent with the opinion." Standards for Consultative Examinations and Existing Medical Evidence, 56 FR 36932-01 at 36936; see Torres v. Barnhart, 139 Fed.Appx. 411, 414 (3d Cir. 2005) (ALJ permissibly rejected treating opinion "in combination with other evidence of record including Claimant's own testimony"). In this case, however, there simply is not enough evidence, medical or non-medical, that is inconsistent with the doctor's opinion which would justify rejecting Dr. Upadhyay's medical opinion. Therefore, further development and explanation of the medical evidence is necessary here.

While case law calls for a remand and further proceedings by the ALJ in this case, nothing in our opinion should be construed as suggesting what the outcome of that final and full analysis should be. Rather, that final assessment of the evidence must await a thorough consideration and development of this evidence on remand by an ALJ. Therefore, nothing in this Report and Recommendation should be deemed as expressing an opinion on what the ultimate outcome of any reassessment of this evidence should be. Rather, that task should remain the duty and province of the ALJ on remand.

IV. Recommendation

Accordingly, for the foregoing reasons, IT IS RECOMMENDED that Mr. Hynd's request for a new administrative hearing be GRANTED and the Commissioner's final decision denying Mr. Hynd's claims be VACATED as follows:

The parties are further placed on notice that pursuant to Local Rule 72.3:

Failure to file timely Objections to the foregoing Report and Recommendation may constitute a waiver of any appellate rights.