Opinion

Schultz v. Commissioner of Social Security

Court
District Court, E.D. New York
Filed
Sep 25, 2020
Cited by
0 cases
Authority
More cited than 26.5%

“[F]ibromyalgia is a disabling impairment and [] ‘there are no objective tests which can conclusively confirm the disease.’” (citation omitted)

How later courts described this case

  • “[F]ibromyalgia is a disabling impairment and [] ‘there are no objective tests which can conclusively confirm the disease.’” (citation omitted)
  • “Because an RFC determination is a medical determination, an ALJ who makes an RFC determination in the absence of supporting expert medical opinion has improperly substituted his own opinion for that of a physician, and has committed legal error.” (citations omitted)
  • “[E]ven if the clinical findings were inadequate, it was the ALJ’s duty to seek additional information . . . sua sponte.”
  • noting that “[a]n ALJ need not recite every piece of evidence that contributed to the decision, so long as the record permits [the court] to glean the rationale of an ALJ’s decision.” (internal quotation marks omitted)

Written by the judges who cited it.

The opinion

UNITED STATES DISTRICT COURT

EASTERN DISTRICT OF NEW YORK

-------------------------------------------------------x

SUSAN SCHULTZ,

Plaintiff,

MEMORANDUM & ORDER

- against - 18-CV-5919 (PKC)

ANDREW SAUL, Commissioner of Social

Security,1

Defendant.

-------------------------------------------------------x

PAMELA K. CHEN, United States District Judge:

Plaintiff Susan Elizabeth Schultz brings this action under 42 U.S.C. § 405(g), seeking

judicial review of the decision made by the Commissioner of the Social Security Administration

(“SSA”) denying her claim for Social Security Disability Insurance Benefits (“DIB”). Before the

Court are the parties’ cross-motions for judgment on the pleadings. (Dkts. 14, 16.) For the reasons

that follow, the Court grants Plaintiff’s motion for judgment on the pleadings, denies the

Commissioner’s cross-motion, and remands this matter for further administrative proceedings.

1 Andrew Saul became Commissioner of the Social Security Administration on June 17,

2019. Pursuant to Federal Rule of Civil Procedure 25, Andrew Saul is substituted as Defendant in

this action. Fed. R. Civ. P. 25(d); see 42 U.S.C. § 405(g) (“Any action instituted in accordance

with this subsection shall survive notwithstanding any change in the person occupying the office

of Commissioner of Social Security or any vacancy in such office.”). The Clerk of Court is

respectfully directed to update the docket accordingly.

BACKGROUND

I. Procedural History

On February 3, 2015, Plaintiff filed an application for DIB, alleging disability beginning

on July 7, 2014. (Administrative Transcript (“Tr.”),2 Dkt. 12, at 15.) On June 3, 2015, Plaintiff’s

application was initially denied. (Id. at 15, 92–95.) Plaintiff then filed a request for a hearing

before an administrative law judge (“ALJ”). (Id. at 96–97.) On August 22, 2017, Plaintiff

appeared by video with counsel for a hearing before ALJ John R. Allen. (Id. at 34–80.) In a

decision dated September 1, 2017, the ALJ determined that Plaintiff was not disabled under the

Social Security Act (the “Act”) and therefore not eligible for the benefits for which she had applied.

(Id. at 12–27.) On August 21, 2018, the ALJ’s decision became final when the Appeals Council

of the SSA’s Office of Disability Adjudication and Review denied Plaintiff’s request for review

of the decision. (Id. at 1–6.) This appeal timely followed.3

2 Page references prefaced by “Tr.” refer to the continuous pagination of the Administrative

Transcript (appearing in the lower right corner of each page) and not to the internal pagination of

the constituent documents or the pagination generated by the Court’s CM/ECF docketing system.

3 According to Title 42, United States Code, Section 405(g),

[a]ny individual, after any final decision of the Commissioner of Social Security

made after a hearing to which he was a party . . . may obtain a review of such

decision by a civil action commenced within sixty days after the mailing to him of

notice of such decision or within such further time as the Commissioner of Social

Security may allow.

42 U.S.C. § 405(g). “Under the applicable regulations, the mailing of the final decision is

presumed received five days after it is dated unless the claimant makes a reasonable showing to

the contrary.” Kesoglides v. Comm’r of Soc. Sec., No. 13-CV-4724 (PKC), 2015 WL 1439862, at

*3 (E.D.N.Y. Mar. 27, 2015) (citing, inter alia, 20 C.F.R. §§ 404.981, 422.210(c)). Applying this

standard, the Court determines that because Plaintiff received the Commissioner’s final decision

on August 26, 2018 and Plaintiff filed the instant action on October 23, 2018—58 days later—this

appeal is timely. (See generally Complaint, Dkt. 1.)

II. The ALJ’s Decision

In evaluating disability claims, the ALJ must adhere to a five-step inquiry. The claimant

bears the burden of proof in the first four steps of the inquiry; the Commissioner bears the burden

in the final step. Talavera v. Astrue, 697 F.3d 145, 151 (2d Cir. 2012). First, the ALJ determines

whether the claimant is currently engaged in “substantial gainful activity.” 20 C.F.R.

§ 404.1520(a)(4)(i). If the answer is yes, the claimant is not disabled. Id. If the answer is no, the

ALJ proceeds to the second step to determine whether the claimant suffers from a severe

impairment. Id. § 404.1520(a)(4)(ii). An impairment is severe when it “significantly limits [the

claimant’s] physical or mental ability to do basic work activities.” Id. § 404.1520(c). If the

impairment is not severe, then the claimant is not disabled. In this case, the ALJ found that Plaintiff

suffers from the following severe impairments: fibromyalgia, cervical degenerative disc disease

status post discectomy and fusion, lumbar degenerative disc disease, and migraine headache

disorder. (Tr. at 17 (citation omitted).) The ALJ also determined that Plaintiff’s diagnoses of

asthma, foot and ankle pain, hand and arm pain, postural orthostatic tachycardia syndrome

(“POTS”), 4 anxiety disorder, depression, bereavement, and chronic pain were non-severe

impairments. (Id. at 18–19.) The ALJ then progressed to the third step and determined that

Plaintiff’s severe impairments did not “meet[] or medically equal[] 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

4 POTS is part “of a group of disorders that have orthostatic intolerance (OI) as their

primary symptom. OI describes a condition in which an excessively reduced volume of blood

returns to the heart after an individual stands up from a lying down position. The primary symptom

of OI is lightheadedness or fainting.” Postural Tachycardia Syndrome Information Page, Nat’l

Inst. Neurological Disorders & Stroke, https://www.ninds.nih.gov/Disorders/All-

Disorders/Postural-Tachycardia-Syndrome-Information-Page (last visited Sept. 25, 2020).

404.1526)”—the Listings. (Id. at 19.) Moving to the fourth step, the ALJ found that Plaintiff

maintained the residual functional capacity (“RFC”)5 to perform

sedentary work 6 as defined in 20 CFR 404.1567(a) except she can only

occasionally overhead reach bilaterally. She may not perform tasks involving

frequent head turn or prolonged upward or downward gaze. She can occasionally

climb stairs or ramps, but never ladders, ropes, or scaffolds. The claimant can

occasionally bend or stoop; but she may not crouch, crawl. She must be allowed to

change position approximately every 30 minutes, but could stay on task while doing

so. Finally, she must not be required to perform fast-paced or strict time-limited

tasks, such as assembly line work.

(Id. at 19.) Based upon this RFC finding, the ALJ determined that, although Plaintiff was not

capable of performing her past relevant work as a medical assistant, “there are jobs that exist in

significant numbers in the national economy that the claimant can perform,” such as order clerk,

inspector, and packager. (Id. at 25, 26.) Accordingly, the ALJ concluded that Plaintiff was not

disabled under the Act. (Id. at 27.)

STANDARD OF REVIEW

Unsuccessful claimants for disability benefits under the Act may bring an action in federal

district court seeking judicial review of the Commissioner’s denial of their benefits. 42 U.S.C.

§ 405(g). In reviewing a final decision of the Commissioner, the Court’s role is “limited to

5 To determine the claimant’s RFC, the ALJ must consider the claimant’s “impairment(s),

and any related symptoms . . . [which] may cause physical and mental limitations that affect what

[the claimant] can do in a work setting.” 20 C.F.R. § 404.1545(a)(1).

6 According to the applicable regulations,

[s]edentary work involves lifting no more than 10 pounds at a time and occasionally

lifting or carrying articles like docket files, ledgers, and small tools. Although a

sedentary job is defined as one which involves sitting, a certain amount of walking

and standing is often necessary in carrying out job duties. Jobs are sedentary if

walking and standing are required occasionally and other sedentary criteria are met.

20 C.F.R. § 404.1567(a).

determining whether the SSA’s conclusions were supported by substantial evidence in the record

and were based on a correct legal standard.” Talavera, 697 F.3d at 151 (internal quotation marks

omitted). “Substantial evidence is more than a mere scintilla. It means such relevant evidence as

a reasonable mind might accept as adequate to support a conclusion.” Selian v. Astrue, 708 F.3d

409, 417 (2d Cir. 2013) (internal quotation marks and alterations omitted). In determining whether

the Commissioner’s findings were based upon substantial evidence, “the reviewing court is

required to examine the entire record, including contradictory evidence and evidence from which

conflicting inferences can be drawn.” Id. (internal quotation marks omitted). If there is substantial

evidence in the record to support the Commissioner’s findings as to any fact, those findings are

conclusive and must be upheld. 42 U.S.C. § 405(g); see also Cichocki v. Astrue, 729 F.3d 172,

178 n.3 (2d Cir. 2013) (noting that “[a]n ALJ need not recite every piece of evidence that

contributed to the decision, so long as the record permits [the court] to glean the rationale of an

ALJ’s decision.” (internal quotation marks omitted)). Ultimately, the reviewing court “defer[s] to

the Commissioner’s resolution of conflicting evidence,” Cage v. Comm’r of Soc. Sec., 692 F.3d

118, 122 (2d Cir. 2012), and, “[i]f evidence is susceptible to more than one rational interpretation,

the Commissioner’s conclusion must be upheld,” McIntyre v. Colvin, 758 F.3d 146, 149 (2d Cir.

2014) (citation omitted).

DISCUSSION

Plaintiff argues, inter alia, that the ALJ did not accord proper weight to the medical

evidence, and thus failed to properly evaluate her RFC. (Memorandum of Law in Support of

Plaintiff’s Motion for Judgment on the Pleadings (“Pl.’s Mem.”), Dkt. 14, at 19–22.) The Court

agrees,7 and finds that the ALJ erred by (1) affording “little to partial weight” to the opinion of

Plaintiff’s longtime treating physician, Dr. Anthony Foto, D.O. (Tr. at 23, 540–46, 1090–93);

(2) failing to consider or accord any weight to the other physicians whose reports constituted

medical evidence, including Drs. Adam Schneider, M.D., Dean Mitchell, M.D., and Andrew

Porges, M.D. (compare id. at 21–23 (outlining the medical evidence submitted by Plaintiff), with

id. at 23–25 (assigning weight to the medical opinion evidence)); and (3) failing to elicit additional

medical testimony and sufficiently developing the record, and substituting his own lay opinion for

that of medical professionals (id. at 25).

I. Failure to Afford Proper Weight to Plaintiff’s Treating Physician

The SSA has mandated specific procedures an ALJ must follow when considering the

weight to assign a treating physician’s opinion.8 See 20 C.F.R. § 404.1527. “[T]he opinion of a

[plaintiff]’s treating physician as to the nature and severity of the impairment is given ‘controlling

weight’ so long as it ‘is well-supported by medically acceptable clinical and laboratory diagnostic

techniques and is not inconsistent with the other substantial evidence in the case record.’” Burgess

v. Astrue, 537 F.3d 117, 128 (2d Cir. 2008) (alteration omitted) (quoting 20 C.F.R.

7 Because remand is warranted based on the ALJ’s failure to accord proper weight to the

medical evidence, the Court need not reach Plaintiff’s arguments that the ALJ failed to consider

the side effects of her medications and lower extremity impairments, or properly credit Plaintiff’s

statements regarding the severity of her pain and impairments. (See Pl.’s Mem., Dkt. 14, at 23–

26.)

8 Although “[t]he current version of the [Act]’s regulations eliminates the treating

physician rule,” the rule nevertheless applies to Plaintiff’s claim, as the current regulations apply

only “to cases filed on or after March 27, 2017.” Burkard v. Comm’r of Soc. Sec., No. 17-CV-290

(EAW), 2018 WL 3630120, at *3 n.2 (W.D.N.Y. July 31, 2018) (citing 20 C.F.R. § 404.1520(c));

see also 20 C.F.R. § 404.1520(c). Because Plaintiff’s claim was filed on February 3, 2015 (Tr. at

15), the treating physician rule applies.

§ 404.1527(d)(2)). There are several factors that an ALJ must explicitly consider when weighing

medical evidence. As the Second Circuit has explained:

An ALJ who refuses to accord controlling weight to the medical opinion of a

treating physician must consider various factors to determine how much weight to

give to the opinion. Among those factors are: (i) the frequency of examination and

the length, nature and extent of the treatment relationship; (ii) the evidence in

support of the treating physician’s opinion; (iii) the consistency of the opinion with

the record as a whole; (iv) whether the opinion is from a specialist; and (v) other

factors brought to the [SSA]’s attention that tend to support or contradict the

opinion. The regulations also specify that the Commissioner will always give good

reasons in her notice of determination or decision for the weight she gives

claimant’s treating source’s opinion.

Halloran v. Barnhardt, 362 F.3d 28, 32 (2d Cir. 2004) (per curiam) (internal quotation marks,

citations, and alterations omitted); see also Estrella v. Berryhill, 925 F.3d 90, 95–96 (2d Cir. 2019);

Burgess, 537 F.3d at 129. “Before the ALJ can disregard a treating physician’s medical opinion,

the ALJ must first ask the treating physician to clarify the deficiencies the ALJ perceives in that

opinion.” Austin v. Comm’r of Soc. Sec., No. 18-CV-331 (PKC), 2019 WL 4751808, at *6

(E.D.N.Y. Sept. 30, 2019) (citation omitted). Furthermore, while an ALJ is entitled to disregard

the opinion of a plaintiff’s treating physician after providing the physician the opportunity to

correct the deficiencies in his or her medical reports, the ALJ must make clear that this decision is

based on conclusions made by other medical professionals. See Greek v. Colvin, 802 F.3d 370,

375 (2d Cir. 2015) (“The ALJ is not permitted to substitute his own expertise or view of the

medical proof for the treating physician’s opinion or for any competent medical opinion.” (citation

omitted)); Brown v. Comm’r of Soc. Sec., No. 18-CV-1994 (RRM), 2020 WL 2836758, at *11

(E.D.N.Y. May 28, 2020) (“The opinion of a treating physician is given extra weight because of

his unique position resulting from the continuity of treatment he provides and the

doctor/patient relationship he develops.” (emphasis in original) (internal quotation marks and

alteration omitted) (quoting Petrie v. Astrue, 412 F. App’x 401, 405 (2d Cir. 2011) (summary

order))); Hilsdorf v. Comm’r of Soc. Sec., 724 F. Supp. 2d 330, 347 (E.D.N.Y. 2010) (“Because

an RFC determination is a medical determination, an ALJ who makes an RFC determination in

the absence of supporting expert medical opinion has improperly substituted his own opinion for

that of a physician, and has committed legal error.” (citations omitted)).

Dr. Foto, Plaintiff’s primary doctor and a doctor of osteopathy, began treating Plaintiff in

2002. (Tr. at 540; see also Pl.’s Mem., Dkt. 14, at 20–21.) In July 2014, Dr. Foto diagnosed

Plaintiff with fibromyalgia, chronic headaches, and chronic pain, and noted that she could not

return to her prior work as a medical assistant due to these conditions. (Tr. at 365; id. at 371

(indicating that Plaintiff was unable to work beginning on July 7, 2014 and through at least 2024).)

At the time of her diagnosis, Plaintiff’s symptoms included extreme tremors upon too much

physical exertion, forgetfulness, difficulty concentrating, stumbling while walking, and dropping

things. (Id. at 373.) On March 24, 2015, Dr. Foto opined in a disability questionnaire that Plaintiff

could lift or carry less than twenty pounds occasionally, stand or walk for less than two hours in

an eight-hour workday, and could sit without limitation only if provided lumbar support. (Id. at

544–45.) He also opined that Plaintiff had pulling and pushing limitations in her left shoulder and

postural limitations due to her disc herniation at L4-L5. (Id. at 545.) Dr. Foto relied on range of

motion examinations in reaching his conclusion, including specific data indicating that Plaintiff

had reduced ranges of motion in her shoulder, elbow, cervical spine, and lumbar spine. (Id. at

547–48.) He also referred to a June 12, 2014 MRI showing spondylitic9 change at C6-7, and a

January 24, 2013 MRI showing L4-5 disc herniation. (Id. at 542.)

9 “Cervical spondylosis refers to age-related wear and tear affecting the spinal disks in the

neck. As the disks dehydrate and shrink, signs of osteoarthritis develop, including bony projects

along the edges of bones.” Rivera v. Berryhill, No. 16-CV-5021 (PKC), 2018 WL 388942, at *3

n.10 (E.D.N.Y. Jan. 12, 2018) (internal quotation marks, citation, and alteration omitted).

On December 13, 2016, Dr. Foto completed another medical statement regarding

Plaintiff’s physical and exertional limitations. (Id. at 664–71.) Dr. Foto noted that Plaintiff could

stand for fifteen minutes and sit for fifteen minutes at one time, but could not stand or walk at all

in the workday context. (Id. at 664.) He also concluded that Plaintiff could occasionally lift five

pounds, but could not lift any weight on a frequent basis, and that he anticipated Plaintiff being

absent from work due to her impairments or treatment more than four days per month. (Id.) In

addition, Dr. Foto opined that Plaintiff could sit or stand for ten minutes without interruption and

walk for fifteen minutes without interruption. (Id. at 667.) Dr. Foto concluded that during an

eight-hour workday, Plaintiff could stand or walk for only thirty minutes in total, or sit for one

hour in total. (Id.) In support of these limitations, Dr. Foto relied upon Plaintiff’s unpalpable

tender points and fibromyalgia,10 neck pain from a C5-6 fusion in 2008, limited range of motion

in her left shoulder, lower back pain at L4-5, calf and lower leg pain with foot extension and

adduction, muscle weakness, chronic pain, severe environmental allergies, and asthma. (Id. at

666, 668–70.)

Finally, on May 23, 2017, Dr. Foto reaffirmed that Plaintiff was suffering from

fibromyalgia, asthma, POTS, cervical spinal stenosis, and L4-5 degenerative disc disease. (Id. at

1090.) He identified bilateral pain in Plaintiff’s lumbosacral, cervical, and thoracic spine; chest;

shoulders; arms; hands/fingers; hips; legs; and knees, ankles, and feet. (Id. at 1091.) The pain was

10 “Fibromyalgia is [] often characterized by additional pain when firm pressure is applied

to specific areas of [the] body, called tender points.” Fibromyalgia: Understand How It’s

Diagnosed, Mayo Clinic, https://www.mayoclinic.org/diseases-conditions/fibromyalgia/in-

depth/fibromyalgia-symptoms/art-20045401 (last visited July 6, 2020). “Prior to 2010, at least 11

of these 18 [tender] points had to test positive for tenderness for [a] doctor to officially diagnose

[someone] with fibromyalgia.” What Are Fibromyalgia Tender Points?, HEALTHLINE (May 30,

2020), https://www.healthline.com/health/fibromyalgia/fibromyalgia-tender-points (last visited

Sept. 25, 2020). Although the diagnostic criteria “has since changed,” “tender point examinations

are still a common diagnostic tool.” Id.

“widespread,” with “daily throbbing.” (Id.) The clinical findings he relied on included lab work

and observation of Plaintiff’s range of motion, multi-joint pain, and tender points. (Id. at 1090.)

Based on Plaintiff’s symptoms, Dr. Foto concluded that Plaintiff had the following limitations: she

could sit for fifteen minutes at one time and stand for ten minutes at one time; she could sit, stand,

and walk for less than two hours in an eight-hour workday; she could rarely lift or carry up to ten

pounds; she could rarely twist, occasionally climb stairs, and never stoop, crouch, or climb ladders;

and she could never look down or turn her head right or left, and could only rarely look up. (Id. at

1091–92.) Due to these limitations, Dr. Foto opined that, during an eight-hour workday, Plaintiff

would require the ability to shift position at will, take four to five unscheduled breaks of twenty to

thirty minutes each, and be off-task twenty-five percent or more of the time. (Id. at 1091–93.)

The ALJ’s decision to assign “little to partial weight” to Dr. Foto’s opinion is not

substantiated by evidence in the record, especially in light of Plaintiff’s fibromyalgia diagnosis.

Dr. Foto had a long-term relationship with Plaintiff (see, e.g., Tr. at 365–373, 560–658), and

“longitudinal records reflecting ongoing medical evaluation and treatment from acceptable

medical sources are especially helpful in establishing both the existence and severity of

[fibromyalgia],” Campbell v. Colvin, No. 13-CV-451 (GLS) (ESH), 2015 WL 73763, at *5

(N.D.N.Y. Jan. 6, 2015) (emphasis and internal citation omitted). Additionally, it was error for

the ALJ to allocate “little to partial weight” to Dr. Foto’s opinion, especially his December 2016

medical evaluation, on the basis that Plaintiff’s identified symptoms waxed and waned and were,

at times, inconsistent with Plaintiff’s physical examinations. (Tr. at 23.) See id. (noting that

individuals experiencing symptoms of fibromyalgia “may have bad days and good days” (internal

quotation marks and citation omitted)). Moreover, the ALJ’s discounting of Dr. Foto’s assessment

of Plaintiff’s limitations and the severity of her fibromyalgia is inconsistent with case law in this

Circuit insofar as it was based on Plaintiff’s subjective complaints rather than objective medical

evidence. See Green-Younger v. Barnhart, 335 F.3d 99, 108 (2d Cir. 2003) (“[F]ibromyalgia is a

disabling impairment and [] ‘there are no objective tests which can conclusively confirm the

disease.’” (citation omitted)); Campbell, 2015 WL 73763, at *11 (“[R]eliance on subjective

complaints in fibromyalgia cases hardly undermines medical opinion as to functional limitations

it produces because patients’ reports of complaints and histories are essential diagnostic tools.”);

cf. Dougherty-Noteboom v. Berryhill, No. 17-CV-243 (HBS), 2018 WL 3866671, at *7 (W.D.N.Y.

Aug. 15. 2018) (finding, in the context of assessing a plaintiff’s credibility, that “fibromyalgia

frequently presents without objective evidence, and [] it would be erroneous to dismiss [the

plaintiff’s] subjective complaints purely based on a lack of corroborating objective evidence.”)

(collecting cases). Remand is warranted with respect to “denials of disability claims based on

fibromyalgia where the ALJ’s determination turned on the lack of ‘objective’ evidence in the

record to support the claimant’s subjective complaints of pain.” Lim v. Colvin, 243 F. Supp. 3d

307, 316–17 (E.D.N.Y. 2017) (collecting cases).

II. Failure to Consider or Accord Any Weight to Other Medical Evidence

The ALJ’s failure to consider and accord any weight to the other physicians whose reports

constituted medical evidence also constitutes legal error warranting remand. Notably, in August

2014, Dr. Mitchell also diagnosed Plaintiff with fibromyalgia (id. at 838), which was confirmed

by Dr. Porges in September 2014 following a physical examination of Plaintiff that revealed

bilateral elbow tenderness (id. at 385). Yet, the ALJ did not even mention the findings of these

other physicians, despite their consistency with the findings of Plaintiff’s treating physician, Dr.

Foto. This was error and requires remand.

III. Failing to Develop the Record and Substituting Lay Opinion

Finally, to the extent that the ALJ gave little weight to Dr. Foto’s opinion and failed to

solicit any additional medical evidence11 to fill in the gaps in the record, the ALJ both failed to

meet his affirmative duty to develop the record and impermissibly substituted his own lay opinion

for that of a medical expert. See Austin, 2019 WL 4751808, at *6; see also Schaal v. Apfel, 134

F.3d 496, 505 (2d Cir. 1998) (“[E]ven if the clinical findings were inadequate, it was the ALJ’s

duty to seek additional information . . . sua sponte.”). “[W]hile an ALJ is free . . . to choose

between properly submitted medical opinions, he is not free to set his own expertise against that

of a physician who submitted an opinion to or testified before him.” Camille v. Colvin, 652 F.

App’x 25, 28 (2d Cir. 2016) (summary order) (internal quotation marks omitted); see also Hilsdorf,

724 F. Supp. 2d at 347. While an ALJ’s conclusion need “not perfectly correspond with any of

the opinions of medical sources cited in his decision,” Matta v. Astrue, 508 F. App’x 53, 56 (2d

Cir. 2013) (summary order), there must be some competent medical opinion guiding his RFC

determination, Balsamo v. Chater, 142 F.3d 75, 81 (2d Cir. 1998) (“In the absence of a medical

opinion to support the ALJ’s finding as to [plaintiff]’s ability to perform sedentary work, it is well-

settled that ‘the ALJ cannot arbitrarily substitute his own judgment for [a] competent medical

opinion.’” (quoting McBrayer v. Sec’y of Health & Hum. Servs., 712 F.2d 795, 799 (2d Cir.

1983))); see also Perez v. Berryhill, No. 17-CV-3045 (JMA), 2019 WL 1324949, at *5 (E.D.N.Y.

11 Indeed, to the extent there were opinions from other medical sources in the record, the

ALJ gave them little weight, but did not seek out any additional medical evidence. For example,

in May 2015, Consultative Examiner Jerome Caiati, M.D., evaluated Plaintiff and found that she

had no restrictions for sitting, standing, walking, reaching, pushing, pulling, or climbing. (Tr. at

559.) However, the ALJ assigned “little weight” to Dr. Caiati’s opinion because it understated

Plaintiff’s pain and reduced range of motion. (Id. at 25.)

Mar. 25, 2019) (remanding where “the ALJ determined Plaintiff’s RFC based on her own

interpretation of the medical evidence in the record and Plaintiff’s testimony.”). In the total

absence of any credited medical evidence, “the ALJ’s RFC determination that Plaintiff was

capable of sedentary work ‘constituted an impermissible interpretation of bare medical findings’

and is not supported by substantial evidence.” Perez, 2019 WL 1324949, at *6 (quoting Guarino

v. Colvin, No. 14-CV-598 (MAP), 2016 WL 690818, at *2 (W.D.N.Y. Feb. 22, 2016)).

For these reasons, the Court finds that the ALJ failed to adequately develop the record, and

that his determination was not supported by substantial evidence in the record, and remands for

further consideration.

CONCLUSION

For the reasons set forth herein, the Court grants Plaintiff’s motion for judgment on the

pleadings and denies the Commissioner’s cross-motion. The Commissioner’s decision is

remanded for further consideration consistent with this Memorandum and Order. The Clerk of

Court is respectfully directed to enter judgment and close this case.

SO ORDERED.

/s/ Pamela K. Chen

Pamela K. Chen

United States District Judge

Dated: September 25, 2020

Brooklyn, New York

This is a copy of a public record, reproduced as it was published. It is not legal advice, and it may not be the version a court would rely on. Check the official source before you cite it.

A word about cookies

We need a few to keep you signed in and the library working. The rest help us see which pages people use and where they get stuck. They stay off unless you say yes.