Subjective Symptom Testimony and Treating‑Source Deference in Fibromyalgia Claims: Commentary on Hultz v. Bisignano

I. Introduction

The Fourth Circuit’s decision in Crystal Hultz v. Bisignano is a major reaffirmation—and sharpening—of its earlier landmark ruling in Arakas v. Commissioner regarding how Social Security decision‑makers must evaluate fibromyalgia and other conditions that do not lend themselves to objective medical verification.

At its core, the case addresses three intertwined questions:

To what extent may an Administrative Law Judge (ALJ) rely on the absence of objective medical findings to discount a claimant’s subjective testimony about fibromyalgia symptoms?
How must ALJs weigh the opinions of treating rheumatologists in pre‑2017 cases governed by the “Treating Source Rule”?
When is an appellate court justified in not merely vacating a denial of benefits but reversing outright and remanding only for the calculation of benefits?

The majority opinion by Judge Gregory, joined by Judge Young, answers all three in ways that significantly strengthen protections for claimants with fibromyalgia and similar “invisible” impairments. Judge Agee concurs that the ALJ erred under Arakas but dissents from the remedy, warning that the court is moving close to treating fibromyalgia as a de facto automatic disability.

Because fibromyalgia disproportionately affects women and is notoriously difficult to capture through laboratory or imaging studies, the decision has particular importance for gendered patterns of disability adjudication and for any case involving subjective symptom evidence.

II. Summary of the Opinion

A. Facts in Brief

Crystal Hultz, born in 1987 and formerly employed as a computer operator, suffers from multiple conditions, including:

Fibromyalgia (diagnosed 2013)
Lupus (diagnosed 2011)
Spinal disorders (with cervical discectomy and fusion surgery in 2015)
Bilateral knee osteoarthritis
Ulnar neuropathy
Factor V Leiden with prior transient ischemic attacks (mini‑strokes)
Depression and mood disorder

Although surgery and treatment improved several conditions (especially her spinal issues and lupus), Hultz consistently reported—and testified to—chronic, debilitating symptoms she attributes to fibromyalgia: widespread pain, profound fatigue, cognitive difficulties (“fibro fog”), and frequent “flares” (four to eight per month) that confine her to bed for days. Her grandmother testified that the family performs most of the household tasks and caregiving for Hultz and her children.

Hultz applied for Disability Insurance Benefits (DIB) and Supplemental Security Income (SSI), alleging disability beginning January 1, 2014. After initial denials, reconsideration denials, three separate ALJ hearings, an earlier district court remand, and a final ALJ denial by ALJ Simmonds in August 2022, the district court affirmed. Hultz then appealed to the Fourth Circuit.

B. Holding and Disposition

The Fourth Circuit:

Held that the ALJ applied an incorrect legal standard under Arakas by using objective medical evidence to discount Hultz’s subjective complaints of fibromyalgia symptoms, both at step three and in the residual functional capacity (RFC) analysis at step four.
Found that the ALJ’s RFC determination was not supported by substantial evidence, because the decision:
- Cherry‑picked from the medical record
- Misinterpreted Hultz’s daily activities
- Misused treatment gaps and medication non‑compliance without considering fibromyalgia’s nature
- Failed to build the required “accurate and logical bridge” from evidence to conclusions
Held that the ALJ violated the Treating Source Rule by giving “little weight” to the opinion of Hultz’s treating rheumatologist, Dr. Nasser Nasseri, without persuasive contradictory evidence and without properly applying the regulatory factors.
Concluded that the record clearly establishes Hultz’s entitlement to disability benefits and therefore:
- Reversed the Commissioner’s denial of benefits, and
- Remanded solely for calculation of benefits, rather than for further administrative proceedings.

C. The Separate Opinion: Concurrence in Part, Dissent in Part

Judge Agee:

Agrees that, under Arakas, the ALJ committed legal error by relying on objective medical evidence to discount fibromyalgia symptoms.
Disagrees that the record “clearly” establishes disability and that a new hearing would be useless.
Would vacate and remand to the ALJ for further proceedings, not direct an award of benefits.
Expresses broader concerns that Arakas (and now Hultz) push toward treating fibromyalgia as effectively always disabling whenever subjective complaints are asserted, which he views as inconsistent with the Social Security Act’s design and with the ALJ’s fact‑finding role.

III. Detailed Analysis

A. Precedents and Authorities Shaping the Decision

1. Arakas v. Commissioner (4th Cir. 2020)

Arakas is the cornerstone of the majority’s reasoning. The court there held:

Claimants may “rely exclusively on subjective evidence to prove that [their] symptoms were so continuous and/or severe that they prevented [them] from working a full eight‑hour day.” (reaffirming Hines v. Barnhart).
ALJs may not rely on the presence or absence of objective medical evidence—even as one factor—to discount a claimant’s subjective complaints about fibromyalgia symptoms, because:
- Fibromyalgia’s hallmark symptoms (widespread pain, fatigue) are inherently subjective.
- Physical exams are often normal: full range of motion, no swelling, normal strength and reflexes.
ALJs commit reversible error when they:
- Cherry‑pick favorable medical notes and ignore contrary evidence
- Misuse daily activities (like basic self‑care, limited chores) to discredit disability claims
- Rely on “conservative treatment” or episodic improvement to downplay severity of a waxing‑and‑waning condition like fibromyalgia.
The court in Arakas also reversed outright and remanded for a calculation of benefits, finding the record clearly established disability.

Hultz explicitly applies and reinforces these holdings. The majority notes that the ALJ’s boilerplate language—finding Hultz’s statements “not entirely consistent with the medical evidence and other evidence in the record”—is almost identical to that in Arakas, and used in the same impermissible way: as shorthand for requiring objective corroboration.

2. Hines v. Barnhart (4th Cir. 2006)

Hines, cited in Arakas and reiterated in Hultz, established that:

Subjective evidence alone can prove a disability, particularly in pain‑based conditions.
Claimants are “entitled to rely exclusively on subjective evidence” of pain and its functional consequences.

In Hultz, this principle is applied in its most robust form to fibromyalgia: where the record does not contradict the claimant’s subjective fibromyalgia reports, the court says those reports “must” be treated as true.

3. SSR 96‑8p and the “Logical Bridge” Requirement

Social Security Ruling 96‑8p governs RFC determinations. It requires ALJs to:

Base the RFC on “all the relevant evidence”;
Provide a “narrative discussion” explaining how each RFC finding is supported by specific medical and non‑medical evidence;
Address and resolve “material inconsistencies or ambiguities” in the record;
Explain why reported symptom‑related limitations are accepted or rejected.

The Fourth Circuit has translated this into a requirement that ALJs “build an accurate and logical bridge” between the evidence and the ultimate RFC. (Monroe v. Colvin; cited again in Arakas and here.)

In Hultz, the court criticizes the ALJ for:

Producing a lengthy but mostly descriptive summary of the medical record, with very little analytic linkage to specific RFC findings; and
Concluding, in a conclusory manner, that the RFC was “supported by the entirety of the evidence” without specifying how particular evidence justified particular limitations.

4. The Treating Source Rule – 20 C.F.R. § 404.1527(c)

Because Hultz filed her applications in 2014, the pre‑March 27, 2017 regulations apply. Under the “Treating Source Rule” then in force:

A treating source’s medical opinion on the nature and severity of impairments is given controlling weight if it is:
- Well‑supported by medically accepted clinical and laboratory diagnostic techniques, and
- Not inconsistent with other substantial evidence in the record.
If not controlling, the ALJ must still decide what weight to give it by considering:
- Length of treatment relationship
- Frequency of examination
- Nature and extent of treatment
- Supportability
- Consistency with the record as a whole
- Specialization of the provider
A treating physician’s opinion can be disregarded “only if there is persuasive contradictory evidence.” (Coffman v. Bowen, quoted in Arakas and in Hultz.)

In Dowling v. Commissioner (2021), the Fourth Circuit clarified that while an ALJ need not mechanically tick off each factor, it must be “apparent” the factors were meaningfully considered.

Applying this framework, Hultz finds that ALJ Simmonds erred by:

Assigning “little weight” to treating rheumatologist Dr. Nasseri’s opinion that fibromyalgia significantly limited daily activities, social functioning, and pace/concentration;
Justifying that discounting solely because:
- The opinion form did not quantify the degree of limitation, and
- There were gaps in treatment;
Without engaging with the depth of the treatment relationship, the consistency of his opinion with other evidence (including pain‑management notes and another rheumatologist’s records), or his specialization.

The court emphasizes that no persuasive contradictory evidence existed to justify sidelining his opinion.

5. The Standard of Review and “Substantial Evidence”

The court reiterates the familiar but important standard:

An ALJ’s decision is upheld if the ALJ:
- Applied the correct legal standards, and
- Supported findings with “substantial evidence.”
“Substantial evidence” is “more than a mere scintilla” but may be less than a preponderance.
Reviewing courts do not reweigh evidence or make credibility determinations; they assess whether a reasonable mind could reach the ALJ’s conclusion on the record.

Hultz uses this standard in a demanding way: where the ALJ’s reasoning is legally flawed and the record, fairly read, overwhelmingly supports disability, the court not only vacates but reverses and awards benefits.

6. Other Authorities (Particularly from the Dissent)

Judge Agee’s partial dissent canvasses broader administrative and Social Security jurisprudence to argue for remand rather than direct reversal:

Remand as the usual remedy for legal error:
- NLRB v. Local 638: courts ordinarily correct legal error and then remand for fact‑finding by the agency.
- Radford v. Colvin (4th Cir.): appellate courts should not weigh evidence or make credibility determinations “in the first instance.”
- Schwarzbaum (11th Cir.): remand is generally appropriate when an agency errs in law, to let it reconsider in light of the correct standards.
Scope of Arakas and expansion to other conditions:
- Shelley C. v. Commissioner (4th Cir. 2023) – extended the Arakas rule to chronic depression, holding that ALJs cannot use lack of “objective” psychiatric markers to discredit subjective depression complaints.
- Other circuits’ fibromyalgia cases (Revels, Green‑Younger, Rogers, Sarchet, Brosnahan) – most vacate and remand but do not typically direct benefit awards.

These authorities underscore the dissent’s concern that the majority’s remedial approach is moving beyond standard practice in administrative review.

B. The Court’s Legal Reasoning

1. Misapplication of Arakas at Step Three and in RFC Assessment

The majority identifies two primary legal errors under Arakas:

Step Three – Listing Equivalence
Fibromyalgia is not a listed impairment, so the ALJ evaluated whether it medically equaled Listing 14.09D (inflammatory arthritis). The ALJ concluded it did not, citing:
- No documented need for a mobility device
- No involvement of two or more organs/body systems at required severity
- No ankylosing spondylitis or spondyloarthropathy
- No “marked” limitations in daily living, social functioning, or timely task completion
The majority notes that the first three rationales are heavily grounded in objective signs and findings—the precise type of criteria fibromyalgia typically does not produce, and that Arakas says cannot be used to discount fibromyalgia symptoms.
Step Four – RFC and Credibility
In assessing RFC, the ALJ discounted Hultz’s and her grandmother’s testimony, stating—almost verbatim as in Arakas—that their statements about “intensity, persistence, and limiting effects” were “not entirely consistent with the medical evidence and other evidence in the record.”

The majority reads this as the same prohibited move: requiring objective support for inherently subjective fibromyalgia symptoms. As Arakas holds, ALJs “may not rely on objective medical evidence (or the lack thereof)—even as just one of multiple factors—to discount” subjective complaints of fibromyalgia.

Although the Commissioner argued that the ALJ also considered other factors (daily activities, treatment history), the majority, echoing Arakas, finds that the ALJ’s analysis in substance rested on objective evidence and that even “one factor” reliance on objective deficits is forbidden in this context.

2. Substantial Evidence and the Prohibition on Cherry‑Picking

Beyond legal error, the majority finds that the ALJ’s decision is not supported by substantial evidence because:

Omitted critical evidence:
- For nearly two years, pain specialist Dr. Reider recorded Hultz’s pain as fluctuating between 4/10 and 10/10 and described it as chronic, aching, throbbing, and stabbing.
- Records from 2018–2022 show continued chronic pain management, even if note formats changed and narratives were shorter.
The ALJ selectively emphasized notes showing temporary improvement or effectiveness of medications while failing to engage with the long‑term pattern of persistent, high‑level pain.
Mischaracterized or over‑simplified treatment history:
The ALJ inferred that gaps in rheumatology follow‑up and periods off medication suggested symptom resolution or effective control.

The majority counters that:
- The record shows that depression and “fibro fog” contributed to medication non‑compliance; forgetting or discontinuing medication is itself consistent with cognitive and mental impairments.
- Fibromyalgia is chronic and often not meaningfully “treated” beyond symptomatic management; repeated visits and strong medications can themselves carry costs and risks, and some painkillers may exacerbate symptoms over time.
- There is no analysis by the ALJ explaining why treatment gaps actually indicate improvement, especially when both testimony and other records show continuing severe symptoms.
Overreliance on “good days” and daily activities:
The ALJ cited episodes where Hultz reported being “very active” with her children, going camping, walking and climbing more, and using pain medication to “function to continue to take care of her children.”

The majority notes: fibromyalgia waxes and wanes. Episodic improvement and intermittent ability to engage in family activities are not inconsistent with disability. As Arakas said, “being able to live independently and participate in the everyday activities of life” should not be used against claimants, particularly when the question is their ability to sustain full‑time work on a regular and continuing basis.
Insufficient explanation of RFC findings:
After summarizing the medical history, the ALJ simply declared that the RFC was “supported by the entirety of the evidence” without tying specific evidence to specific functional limits (e.g., why four hours standing/walking, why full eight hours sitting, why only unskilled work).

This violates SSR 96‑8p’s narrative requirement and the “logical bridge” principle.

When the omitted and mischaracterized evidence is considered, the majority concludes that the record, properly read, strongly corroborates Hultz’s account of chronic, debilitating fibromyalgia.

3. Treating Rheumatologist’s Opinion and the Treating Source Rule

The ALJ gave “little weight” to the opinion of treating rheumatologist Dr. Nasseri, who:

Began treating Hultz in December 2015;
Observed that lupus was well‑controlled but that her symptoms “were mostly coming from her fibromyalgia”;
Recorded ongoing diffuse arthralgias (joint pain), myalgias (muscle pain), fatigue, and hours‑long stiffness;
In March 2016, noted that chronic pain and fatigue made daily activities “very difficult” and that she needed help with cleaning, bathing, dressing, and cooking;
In November 2017, filled out a form indicating fibromyalgia limited:
- Activities of daily living
- Social functioning
- Ability to complete tasks in a timely manner (concentration, persistence, pace)

The ALJ discounted this opinion because:

The form did not specify the of limitations; and
There was roughly a year‑long gap in treatment before the form was completed.

The majority finds this approach incompatible with § 404.1527(c) and Coffman/Dowling:

The ALJ did not meaningfully consider:
- The treating relationship (multi‑year, specialized care)
- Consistency with other longitudinal evidence (Reider’s notes, later rheumatologist Dr. Talebi’s notes, Grandma’s testimony)
- The rheumatologist’s specialization and role as primary fibromyalgia provider.
The treatment gaps, without more, do not equate to symptom resolution and are themselves consistent with fibromyalgia’s nature and the burden of treatment.
Most importantly, there is no “persuasive contradictory evidence”:
- State agency consultants and the consultative neurologist, Dr. Shawney, relied heavily on normal objective findings and even suggested “malingering.” That is exactly the kind of reasoning Arakas rejects in fibromyalgia cases.
- Other evidence—from pain management and later rheumatology treatment—largely aligns with Nasseri’s description of significant, chronic limitations.

The court analogizes to Arakas, where it rejected similar discounting of a treating rheumatologist, emphasizing coordinated care, supported diagnosis, comorbid degenerative disc disease, and lack of improvement despite intensive treatment. Though the treatment duration here is shorter, the core pattern is similar.

4. Remedy: Reversing and Remanding for Calculation of Benefits

Under 42 U.S.C. § 405(g), courts may:

Affirm;
Modify;
Reverse; or
Reverse and remand for further proceedings or for calculation of benefits.

The Fourth Circuit has held (including in Arakas) that direct awards of benefits are appropriate when:

The record clearly establishes entitlement to benefits; and
Another ALJ hearing would serve no useful purpose.

The majority finds both conditions met:

The nature of fibromyalgia means that “additional medical evidence” in the form of new labs or imaging would not add much; modern medicine cannot generate objective markers for the disease.
The record already contains:
- Years of documented chronic pain, fatigue, and functional limitations;
- Specialist treatment (rheumatologists and pain management), showing persistent symptoms despite varied interventions;
- Consistent testimony from Hultz and her grandmother about being bedridden multiple days per month, and needing substantial assistance even on “good” days;
- A treating physician opinion consistent with that record.
The court states explicitly: where the medical record does not contradict a patient’s reports of debilitating fibromyalgia, “we must treat those reports as true.”
The majority underscores that:
- Fibromyalgia is chronic, untreatable in the sense of cure, and painful.
- It disproportionately affects women, a population historically under‑studied and under‑credited in medical and legal contexts.
- Young claimants like Hultz, who applied in her twenties, do not “reasonably seek to be disabled, bedridden, and dependent on government funds,” reinforcing the credibility of their reports.

On that basis, the court concludes that another ALJ hearing would not change the outcome and that it should, as in Arakas, reverse and remand solely for the calculation of benefits.

5. The Dissent’s Objections to the Remedy

Judge Agee accepts that Arakas requires finding error, but sharply disagrees with skipping a new hearing:

He emphasizes that legal error is conceptually distinct from disability on the merits. Correcting the former does not automatically answer the latter; that is the ALJ’s job on remand.
He stresses that standard administrative law practice is to remand for further fact‑finding when an error of law occurs, citing Supreme Court and circuit precedent.
He notes that:
- There is conflicting evidence in the record (e.g., consultative neurologist’s “malingering” comment, notes describing symptoms as “stable” or “well‑controlled,” self‑reports of being “very active” with children).
- On such a record, reasonable minds could differ; appellate judges should not “wade into that fact‑intensive arena” in the first instance.
He argues that remand would serve at least two “useful purposes”:
- Allowing ALJs to apply Arakas properly and refine their understanding of subjective‑evidence conditions.
- Permitting fuller development of the record, particularly focused on function during flares and over time.
He expresses concern that the majority’s reasoning—focused on fibromyalgia’s subjective nature and lack of objective markers—could practically mean that “absent unmistakable fraud, [he finds it] difficult to project any fibromyalgia claimant who could be denied disability benefits.”

In short, the dissent sees the majority as overstepping the appellate role and eroding the distinction between having fibromyalgia and being disabled by it.

C. Impact and Significance

1. For ALJs and the Social Security Administration

Within the Fourth Circuit, Hultz—combined with Arakas and Shelley C.—sends a very strong message about adjudicating conditions whose primary manifestations are subjective (fibromyalgia, chronic depression, some pain syndromes):

No objective‑evidence discounting:
- ALJs may not rely on “normal” exams, imaging, or labs (or the absence of abnormalities) as a reason—even as one factor—to disbelieve claimed fibromyalgia symptoms.
- Objective findings, if considered, should generally be used to support the existence of an impairment, not to undercut symptom severity.
Heightened obligation to engage with subjective and third‑party reports:
- Detailed testimony about daily function, flares, and the need to rest or lie down must be carefully evaluated and addressed.
- Third‑party testimony (like that of Hultz’s grandmother) is especially important and cannot be dismissed summarily.
Daily activities must be treated cautiously:
- Evidence that claimants can sometimes shop, cook, attend events, or be “very active” with family does not, by itself, undermine disability, particularly where:
  - Activities are sporadic or require post‑activity rest;
  - They do not reflect full‑time work conditions (predictability, persistence, pace).
Treatment gaps and non‑compliance require context‑sensitive analysis:
- ALJs cannot assume that missed appointments or medication lapses mean symptoms improved.
- They must consider:
  - Psychiatric comorbidities (like depression) that impede adherence;
  - Cognitive issues (“fibro fog”) that cause forgetfulness;
  - Burden, cost, and limited efficacy of repeated pain management visits for chronic, untreatable conditions.
Treating specialists, especially rheumatologists, command strong deference in pre‑2017 cases:
- ALJs must thoroughly analyze the treating rheumatologist’s opinion under § 404.1527(c).
- Discounting is permissible only in the presence of persuasive contradictory evidence, which cannot merely consist of normal objective findings or a brief one‑time consultative exam.

Practically, ALJs in the Fourth Circuit will need to adjust decision templates and analysis in fibromyalgia cases to avoid boilerplate that ties credibility to “consistency with medical evidence” where that phrase effectively means “consistency with objective exams and tests.”

2. For Claimants and Advocates

Hultz strengthens the hand of claimants with fibromyalgia and other subjectively manifested conditions:

Subjective testimony is central and can be dispositive:
- Detailed, consistent descriptions of pain, fatigue, flares, and functional limitations—over time and across providers—carry significant weight.
- Third‑party statements (family, caregivers) corroborating day‑to‑day struggles are particularly valuable.
Gaps in treatment are not automatic red flags:
- Advocates should document reasons for treatment gaps and medication stops (side‑effects, financial barriers, mental health, lack of benefit).
- Hultz can be cited to show that such gaps are often consistent with chronic pain disorders and cannot be used reflexively to infer exaggeration.
Daily activities must be framed in terms of persistence and reliability:
- Explain the difference between occasional, self‑paced activities—with the ability to rest and lie down—and the demands of a full‑time job.
- Document the aftermath of activities (e.g., “If I go to the grocery store, I must lie down the rest of the day”).
Treating rheumatologist opinions are potent (for pre‑2017 filings):
- Ensure treating specialists explicitly describe:
  - Functional limits (sitting, standing, lifting, need to lie down)
  - Effects on concentration, persistence, and pace
  - Likely frequency and duration of flares and absences.
- Hultz underscores that lack of numeric precision does not justify disregarding clear qualitative limitation statements.

3. On the Law of Remedies in Social Security Cases

Hultz reinforces, but also stretches, the Fourth Circuit’s willingness to bypass a new hearing and award benefits directly in some circumstances:

Clear‑record standard:
- When evidence overwhelmingly supports disability and further proceedings would not meaningfully change the outcome, reversal and benefit calculation is proper.
- This is especially true where the impairment is not amenable to further objective testing, as with fibromyalgia.
Tension flagged by the dissent:
- Judge Agee warns that if the absence of contradictory objective evidence plus consistent subjective reports is enough to trigger direct awards, nearly all fibromyalgia claimants could prevail.
- He stresses that ordinarily, legal error leads to vacatur and remand, not reversal.

This internal tension may influence how future panels handle similar cases and could invite en banc or Supreme Court attention, particularly if the appellate court is perceived as encroaching on the agency’s fact‑finding role.

4. Gender and Structural Dimensions

The majority explicitly notes that fibromyalgia “disproportionately affects women” and that women’s health issues have been “historically and woefully understudied.” This recognition has several implications:

Courts are increasingly aware that skepticism toward “invisible” illnesses can disproportionately harm women and other marginalized groups.
By mandating serious engagement with subjective reports and treating‑source opinions, the decision pushes back against structural biases that discount female‑dominant conditions as psychosomatic or exaggerated.

IV. Complex Concepts Simplified

1. What Is Fibromyalgia and Why Is It Legally Difficult?

Fibromyalgia is a chronic disorder characterized by:

Widespread musculoskeletal pain
Extreme fatigue
Sleep disturbances
Cognitive difficulties (“fibro fog”)
Headaches and other somatic complaints

Legally significant features:

No definitive lab test: Diagnosis is mostly clinical (history, tender points, exclusion of other diseases).
Normal exams are common: Patients often have normal strength, reflexes, imaging, and labs—even when pain is disabling.
Symptoms wax and wane: Claimants have good days and bad days; some days they can be fairly active, others they cannot get out of bed.
Associated with mental health and cognitive symptoms: Depression, anxiety, and “fibro fog” often accompany fibromyalgia, affecting adherence to treatment and daily functioning.

Because of these features, standard medical‑legal habits—looking for objective abnormalities—can misfire. That is the problem Arakas and Hultz address.

2. Subjective vs. Objective Evidence

Objective evidence:
- Test results: MRIs, X‑rays, CT scans, blood tests.
- Physician‑observed signs: swelling, deformity, abnormal reflexes, visible lesions.
Subjective evidence:
- The claimant’s own description of symptoms: pain levels, fatigue, dizziness, mental fog.
- Third‑party descriptions from family, friends, caregivers.

In many conditions (e.g., fractures), objective evidence is central. In fibromyalgia and chronic depression, objective evidence is often minimal or absent. Hines, Arakas, Shelley C., and now Hultz recognize that in such cases, subjective evidence can—and sometimes must—carry the weight of proof.

3. The Five‑Step Sequential Evaluation

ALJs follow a mandatory five‑step process:

Working? If claimant is engaging in “substantial gainful activity,” they are not disabled.
Severe impairment? Does the claimant have severe medically determinable impairments expected to last at least 12 months or result in death?
Listing? Does any impairment meet or equal one listed in the SSA’s regulations? If yes, disability is automatic.
Residual Functional Capacity and past work:
- What can the claimant still do, physically and mentally, on a sustained basis?
- Can they still perform any of their past relevant work?
Other work? Considering RFC, age, education, and skills, can the claimant adjust to other work existing in significant numbers in the national economy?

Claimants bear the burden through step four; the Commissioner bears the burden at step five.

4. Residual Functional Capacity (RFC)

RFC is the most a claimant can still do despite limitations. It is expressed in terms like:

Sedentary: mostly sitting, occasional walking and standing, light lifting.
Light: more standing/walking, some lifting up to 20 pounds.
And so on (medium, heavy, very heavy).

RFC must consider:

Ability to sit, stand, walk, lift, carry, push, pull, reach, stoop, kneel, crouch, crawl;
Mental abilities: concentration, persistence, pace, ability to handle stress, make decisions, interact with others;
Environmental limitations: sensitivity to temperature, light, fumes, hazards.

Crucially, RFC is about capacity to work 8 hours a day, 5 days a week, or equivalent, on a sustained basis. Being able to grocery shop once a week or go camping once a year does not equate to being able to sustain full‑time work.

5. The Treating Source Rule (Pre‑2017)

For older claims like Hultz’s:

Treating physicians—especially specialists—have priority in their opinions about the severity and functional impact of impairments.
If their opinions are well‑supported and not inconsistent with other substantial evidence, they are given “controlling weight.”
Even if not controlling, they are generally entitled to more weight than one‑time consultative examiners or non‑examining reviewers, absent persuasive contradiction.

This rule reflects the view that physicians who have treated a patient over time are better positioned to understand the impairment than brief examiners who see the claimant once.

6. Reverse‑and‑Remand vs. Vacate‑and‑Remand

Vacate and remand for further proceedings:
- Most common remedy when an ALJ commits legal error or fails to explain their reasoning adequately.
- The ALJ re‑evaluates the case under the correct legal standards, possibly taking more evidence.
Reverse and remand for calculation of benefits:
- Reserved for “unusual” cases where:
  - The record clearly supports disability, and
  - Another hearing would serve no useful purpose.
- The court effectively concludes the claimant must be found disabled on the existing record.

Hultz is such a case in the eyes of the majority; the dissent believes it is not, and warns that the majority’s approach may erode the ALJ’s central fact‑finding role.

V. Conclusion and Key Takeaways

Hultz v. Bisignano cements and amplifies the Fourth Circuit’s approach to fibromyalgia and similar conditions:

Subjective symptom testimony is paramount for conditions like fibromyalgia that do not produce objective markers. ALJs cannot require objective corroboration to credit such testimony, even as one factor, and where the record does not contradict it, courts “must” treat it as true.
Treating rheumatologists’ opinions deserve substantial, often controlling, weight in pre‑2017 cases, absent persuasive contradictory evidence grounded in more than normal objective findings.
ALJs must not cherry‑pick episodic improvement, “good days,” or limited daily activities to offset years of documented pain and fatigue, particularly for waxing‑and‑waning conditions.
Gaps in treatment and medication lapses require nuanced analysis, especially when cognitive and mental impairments, financial constraints, and the burdens of chronic pain management are in play.
In appropriate cases, appellate courts may directly award benefits where the record overwhelmingly demonstrates disability and further proceedings would be futile.

At the same time, the dissent underscores an important counterpoint: the need to preserve the ALJ’s role as primary fact‑finder and to resist turning diagnoses like fibromyalgia into automatic disability entitlements. That tension—between robust protection of claimants with invisible illnesses and deference to administrative fact‑finding—will likely shape future litigation in this area.

For practitioners, Hultz is now a leading authority in the Fourth Circuit for:

Challenging denials of fibromyalgia claims that lean on “normal” tests or misinterpret daily activities;
Upholding the centrality of subjective testimony and treating‑specialist opinions;
Arguing, in the right case, for reversal and direct award of benefits rather than another remand.

In the broader legal landscape, the decision is part of a growing recognition that the law must adapt to diseases that defy traditional “objective” measurement but impose very real and often devastating functional limitations—especially on women and other historically under‑credited groups. How courts, agencies, and lawmakers continue to navigate that challenge will be crucial to the fairness and legitimacy of disability adjudication in the years ahead.