The opinion
UNITED STATES DISTRICT COURT
WESTERN DISTRICT OF NEW YORK
JASON A. l.,
Plaintiff, 20-CV-609Sr
v.
COMMISSIONER OF SOCIAL SECURITY,
Defendant.
DECISION AND ORDER
As set forth In the Standing Order of the Court regarding Social Security
Cases subject to the May 21, 2018 Memorandum of Understanding, the parties have
consented to the assignment of this case to the undersigned to conduct all proceedings
in this case, including the entry of final judgment, as set forth in 42 U.S.C. § 405(g).
Dkt. #17.
BACKGROUND
Plaintiff applied for supplemental security income (“SSI”), with the Social
Security Administration (“SSA”), on September 8, 2014, at the age of 34, alleging
disability due to anxiety, panic attacks, obsessive compulsive disorder, attention deficit
disorder (“ADD”), and head trauma. Dkt. #11, p.184.
On February 16, 2017, plaintiff appeared with counsel and testified, along
with an impartial vocational expert (“VE”), Karenna Davis, at an administrative hearing
before Administrative Law Judge (“ALJ”), Julia D. Gibbs. Dkt. #11, pp.28-69. Plaintiff
testified that he had a history of multiple head injuries. Dkt. #11, p.35-39. He found it
nearly impossible to do anything, because he can’t remember anything. Dkt. #11, p.46.
Plaintiff’s first head injury was sustained while playing hockey in 2001. Dkt. #11, pp.52
& 57. Since then he has experienced anxiety and short term memory issues. Dkt. #11,
pp.52-53. Plaintiff experienced continuous anxiety and panic attacks, which often
caused him to vomit. Dkt. #11, pp.54-56. He was still healing from a spiral fracture to
his right tibia and fibula sustained in December of 2015. Dkt. #11, pp.61-62. He has
difficulty sitting for any length of time due to his anxiety and attention deficit
hyperactivity disorder (“ADHD”), which causes him to pace. Dkt. #11, p.64.
Plaintiff went to animal behavior college in 2009, learned from other
animal trainers, and is recognized for his skill at dog training, including for police,
protection and service. Dkt. #11, pp.40 & 58-59. He has been a handler since 2004 and
training since 2006. Dkt. #11, pp.45-46. He testified that he is a phenomenal dog trainer
despite his disability and that police departments are willing to accommodate his
schedule and needs because of his skill. Dkt. #11, p.59. In 2010, he worked at Petco,
but lost the job because of his anxiety. Dkt. #11, p.49. In 2012, he worked for room and
board at Bulox Canine Kennels doing military and police canine training. Dkt. #11,
pp.46-47. In 2013, he worked as an armed security guard for Special Operations
Protection Agency. Dkt. #11, pp.47-48. In the past year, he has worked with
approximately six dogs, including work with Sheriff departments. Dkt. #11, p.41. For the
police dogs, plaintiff testified that he selects the dogs and they live with him during
training. Dkt. #11, p.42. He works with others when he is training dogs to search for
narcotics, for example, but has a hard time working with new people. Dkt. #11, p.57. He
donates the dogs, but receives approximately $2,000 to cover costs. Dkt. #11, p.43.
The VE classified plaintiff’s past work as dog trainer as a skilled, medium
exertion position. Dkt. #11, p.66. When asked if there were any unskilled jobs at the
light exertion level that could be performed either sitting or standing, so that the worker
could alternate between the two positions without having to stop work activity, and that
avoided interacting with the public or working in a large crowd, the VE testified that
plaintiff could work as a weight recorder, marking clerk and hand sander, each of which
were unskilled, light exertion positions. Dkt. #11, p.67. The VE clarified that each of
these positions could be performed with only occasional contact with coworkers or
supervisors. Dkt. #11, pp.68-69. If plaintiff was absent one day per week or off task
10% or more of the work day, the VE testified that he could not sustain employment.
Dkt. #11, p.68.
The ALJ rendered a decision that plaintiff was not disabled on May 9,
2017. Dkt. #11, pp.15-24. The Appeals Council denied review on March 8, 2018. Dkt.
#11, p.6. Plaintiff commenced an action seeking review of the Commissioner’s final
decision on May 3, 2018. 18-CV-508 at Dkt. #1. By Stipulation and Order entered April
1, 2019, the matter was remanded to the Commissioner because the administrative
record contained a medical report for another individual who shared plaintiff’s name.
18-CV-508 at Dkt. #14.
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On October 25, 2019, plaintiff appeared with counsel and testified, along
with his mother and an impartial vocational expert (“VE”), William Cody, at an
administrative hearing before Administrative Law Judge (“ALJ”), David J. Begley. Dkt.
#11, pp. 355-394. Plaintiff’s counsel informed the ALJ that he continued to search for
medical records, but had been unsuccessful, noting that a lot of providers responded
that there was no medical evidence for the dates of service requested. Dkt. #11,
pp.358-359. Plaintiff’s counsel reported that plaintiff’s personality and behavior changed
drastically after he was checked from behind and hit his head on the wooden enclosure
of the penalty box while playing hockey on December 12, 1997. Dkt. #11, p.360.
Plaintiff’s counsel reported that plaintiff suffered another head injury in Florida in 2004
and, most recently, hit his head on cement and suffered a concussion on September
10, 2015. Dkt. #11, pp.360-361.
Plaintiff testified that his anxiety is so bad that he will throw up every five
or ten minutes, sometimes for an entire day. Dkt. #11, p.364. He testified that he was
so anxious that he wouldn’t be able to come to the hearing without getting sick that he
wasn’t able to sleep. Dkt. #11, p.364. He testified that it is very difficult for him to do
anything anymore, even walk out his door. Dkt. #11, p.363. Plaintiff broke his leg after a
fall at Chestnut Ridge while working with a dog for search and rescue in December of
2015. Dkt. #11, pp.378-379. He has been unable to train dogs for the past few years.
Dkt. #11, p.376. Plaintiff’s mother and ex-girlfriend help him with household chores. Dkt.
#11, pp.369-370. Plaintiff attempted to attend Erie Community College in 2000, but his
“brain wasn’t connecting.” Dkt. #11, pp.377-378.
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Plaintiff’s mother testified that, after his head injury at the hockey rink,
plaintiff became a completely different kid - agitated and unable to pay attention or
complete his homework. Dkt. #11, pp.380-381. She would have to drive him to school,
because he would miss the bus and she sat with him in detention to make sure he was
there. Dkt. #11, p.381. He lost his job, which he had loved. Dkt. #11, p.381. He became
short-tempered and had trouble leaving the house. Dkt. #11, p.381. He has attempted
multiple jobs, but none of them last. Dkt. #11, pp.383-384. He has been evicted from
apartments three times. Dkt. #11, pp.385-386. He wants to work with dogs, but his
anxiety is debilitating and prevents him from interacting with their owners. Dkt. #11,
p.387. He cannot remember how to use the washing machine. Dkt. #11, p.387. His
apartment is filthy. Dkt. #11, p.387. He is completely dependent upon her, but also
combative. Dkt. #11, p.388. He vomits constantly. Dkt. #11, p.389. He is not taking
medication because he throws everything up. Dkt. #11, p.389. Although he doesn’t
want to give up trying, plaintiff’s mother did not think he could be successful in a job.
Dkt. #11, p.390.
When asked to assume an individual with plaintiff’s age, education and
past work experience who could work at the light exertional level at simple, repetitive
tasks in a low stress job which was free of fast paced production requirements, no
hazardous conditions, with only occasional decision-making, changes in work setting
and interaction with the public, co-workers and supervisors, the VE testified that plaintiff
could work as a sorter, packer and cleaner housekeeper, each of which were unskilled
jobs performed at the light exertional level. Dkt. #11, p.392. The VE further testified that
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absences of more than two work days per month or off task 15% or more of the
workday would preclude employment. Dkt. #11, p.393.
The ALJ rendered a decision that plaintiff was not disabled on January 28,
2020. Dkt. #11, pp.331-347. Plaintiff commenced this action seeking review of the
Commissioner’s final decision on May 22, 2020. Dkt. #1.
DISCUSSION AND ANALYSIS
“In reviewing a final decision of the SSA, this Court is limited to
determining whether the SSA’s conclusions were supported by substantial evidence in
the record and were based on a correct legal standard.” Talavera v. Astrue, 697 F.3d
145, 151 (2d Cir. 2012). Substantial evidence is defined as “such relevant evidence as
a reasonable mind might accept as adequate to support a conclusion.” Moran v. Astrue,
569 F.3d 496, 501 (2d Cir. 2009). If the evidence is susceptible to more than one
rational interpretation, the Commissioner’s determination must be upheld. McIntyre v.
Colvin, 758 F.3d 146, 149 (2d Cir. 2014). “Where an administrative decision rests on
adequate findings sustained by evidence having rational probative force, the court
should not substitute its judgment for that of the Commissioner.” Yancey v. Apfel, 145
F.3d 106, 111 (2d Cir. 1998).
To be disabled under the Social Security Act (“Act”), a claimant must
establish an inability to do any substantial gainful activity by reason of any medically
determinable physical or mental impairment which can be expected to result in death or
which has lasted or can be expected to last for a continuous period of not less than
twelve months. 20 C.F.R. § 404.1505(a). The Commissioner must follow a five-step
sequential evaluation to determine whether a claimant is disabled within the meaning of
the Act. 20 C.F.R. § 404.1520(a). At step one, the claimant must demonstrate that he is
not engaging in substantial gainful activity. 20 C.F.R. § 404.1520(b). At step two, the
claimant must demonstrate that he has a severe impairment or combination of
impairments that limits the claimant’s ability to perform physical or mental work-related
activities. 20 C.F.R. § 404.1520(c). If the impairment meets or medically equals the
criteria of a disabling impairment as set forth in Appendix 1 of Subpart P of Regulation
No. 4 (the “Listings”), and satisfies the durational requirement, the claimant is entitled to
disability benefits. 20 C.F.R. § 404.1520(d). If the impairment does not meet the criteria
of a disabling impairment, the Commissioner considers whether the claimant has
sufficient RFC for the claimant to return to past relevant work. 20 C.F.R. § 404.1520(e)-
(f). If the claimant is unable to return to past relevant work, the burden of proof shifts to
the Commissioner to demonstrate that the claimant could perform other jobs which
exist in significant numbers in the national economy, based on claimant’s age,
education and work experience. 20 C.F.R. § 404.1520(g).
In the instant case, the ALJ made the following findings with regard to the
five-step sequential evaluation: (1) plaintiff had not engaged in substantial gainful
activity since the application date of September 8, 2014; (2) plaintiff’s obesity, insomnia,
history of traumatic brain injury and history of learning disorder constitute severe
impairments; (3) plaintiff’s impairments did not meet or equal any listed impairment; (4)
plaintiff retained the RFC to perform light work except that he was limited to simple,
routine and repetitive tasks in a low stress job with no hazardous conditions free of fast-
paced production requirements requiring only occasional decision-making or changes in
the work setting and no more than occasional interaction with coworkers and
supervisors, no tandem tasks, and no direct interaction with the general public; and (5)
plaintiff had no past relevant work, but was capable of working as a sorter, packer or
cleaner/housekeper, each of which were unskilled, light exertion positions, and was not,
therefore, disabled within the meaning of the SSA. Dkt. #11, pp.17-24.
Plaintiff argues that the ALJ improperly rejected the opinion evidence of
record, thereby relying improperly upon his own lay opinion in determining an RFC that
was not supported by substantial evidence. Dkt. #16-1, pp.13-17. In light of the limited
weight afforded to the opinions of plaintiff’s medical providers, plaintiff argues that it is
unclear how the ALJ determined plaintiff’s RFC or what medical evidence he relied
upon. Dkt. #16-1, pp.17 & 19. For example, plaintiff argues there is no medical opinion
regarding plaintiff’s capacity to perform work at the light exertional level. Dkt. #16-1,
p.23. Plaintiff also argues that the ALJ failed to provide sufficient reasons for failing to
afford controlling weight to Dr. Chesnutt’s opinions. Dkt. #16-1, p.19. Finally, plaintiff
argues that the ALJ failed to support his determination that the opinion of plaintiff’s
treating physician or licensed mental health counselor was not supported by objective
medical evidence. Dkt. #16-1, pp.21-22.
The Commissioner responds that the ALJ properly assessed the opinion
evidence, giving weight to those portions that were well supported and consistent with
the evidence of record, including generally normal objective clinical examination, lack of
consistent treatment or adherence to medication, and plaintiff’s self-reported activities.
Dkt. #18-1, p.6. The Commissioner notes that Dr. Chestnutt provided four differing
opinions based upon the same assessment, which occurred well before the relevant
period. Dkt. #18-1, pp.8-9. The Commissioner argues that the ALJ’s RFC properly
accounts for the limitations supported by the medical evidence. Dkt. #18-1, pp.11-14.
The Commissioner argues that the ALJ properly considered plaintiff’s conservative and
infrequent treatment and possessed sufficient evidence to render a decision without the
assistance of a consultative examination. Dkt. #18-1, pp.16-17.
Karen Chesnutt, Ph.D., conducted a psychological evaluation of plaintiff
on January 31, 2013 and February 19, 2013 to assess the effects of a traumatic brain
injury. Dkt. #11, p.242. Plaintiff reported significant problems with anxiety, including
some OCD, some claustrophobia, and significant amounts of agoraphobia which made
it difficult for him to successfully engage in any kind of work. Dkt. #11, p.243. She also
reported frequent panic attacks and stomach aches, secondary to stress. Dkt. #11,
p.243. Dr. Chesnutt administered the WAIS IV to plaintiff, who was cooperative, but
appeared to have a significant amount of anxiety about the testing. Dkt. #11, p.243.
Plaintiff scored in the average to low average range of measured intelligence and
exhibited problems with short term memory, expressive langauge and paper and pencil
speed. Dkt. #11, pp.243-243. Dr. Chesnutt reported that plaintiff’s emotional status was
more concerning than his cognitive functioning, reporting:
I found him to have severe levels of anxiety which clearly
interfered with his ability to function. He does have an
element of paranoia, with much concern about his firearms
and security clearance. He reported having panic attacks on
a daily basis. He also reports having difficulty leaving the
house; in fact, his girlfriend had to coax him out of the house
to come to his appointments. She reported that he had lost a
number of dog training jobs because he would fail to go to
work because of his anxiety. There is some evidence that a
head injury can trigger severe levels of anxiety.
Dkt. #11, p.244. Dr. Chesnutt opined that it was “imperative” that plaintiff see a
psychiatrist to get medication to control his anxiety.” Dkt. #11, p.244. She further opined
that plaintiff’s ability to be self-supporting was dependent upon the effectiveness of
medication in treating his anxiety and recommended that plaintiff apply for SSI in the
event that he cannot be fully employed. Dkt. #11, pp.244-245.
On November 4, 2014, Dr. Chesnutt completed a Medical Examination for
Employability Assessment, Disability Screening, and Alcoholism/Drug Addiction
Determination for the New York State Office of Temporary and Disability Assistance
based upon her assessment of plaintiff on January 31, 2013 and February 19, 2013.
Dkt. #11, pp.619-620. Dr. Chesnutt diagnosed plaintiff with severe anxiety and paranoia
and indicated that plaintiff was very limited in his ability to carry out instructions;
maintain attention/concentration; and function in a work setting at a consistent pace.
Dkt. #11, p.255. She also indicated that plaintiff was moderately limited in his ability to
understand and remember instructions; make simple decisions; interact appropriately
with others; and maintain socially appropriate behavior without exhibiting behavior
extremes. Dkt. #11, p.255.
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On May 12, 2015, plaintiff advised his primary care physician, Zuzanna
Rozmus, M.D., that he had been very anxious recently. Dkt. #11, p.591. Dr. Rozmus
observed that plaintiff was anxious and prescribed Lexapro. Dkt. #11, pp.593-594.
On September 15, 2015, plaintiff reported complaints of nausea,
lightheadedness, dizziness, forgetfulness and mood changes following a concussion
sustained when he fell on concrete while training a dog. Dkt. #11, p.587. Dr. Rozumus
observed that plaintiff took a few moments to recall facts and referred plaintiff to a
concussion specialist. Dkt. #11, p.590.
Plaintiff was diagnosed with anxiety during an emergency department visit
at Buffalo General Medical Center on September 17, 2015. Dkt. #11, p.263. Plaintiff
appeared “very upset, very emotional.” Dkt. #11, p.273. He reported drinking alcohol
every evening. Dkt. #11, p.273. A CT of plaintiff’s brain was essentially unremarkable.
Dkt. #11, p.295.
On September 28, 2015, Michael Freitas, M.D., evaluated plaintiff
following his concussion sustained on September 5, 2015. Dkt. #11, p.699. Dr. Freitas
observed that plaintiff’s mood was normal and his affect anxious. Dkt. #11, p.700. His
immediate memory and recall memory was intact. Dkt. #11, p.700. He was able to
concentrate. Dkt. #11, p.700. Dr. Freitas diagnosed plaintiff with a concussion and
noted that he was significantly anxious. Dkt. #11, p.701. Dr. Freitas opined that
plaintiff’s worsening anxiety was worsening his perception of his concussion symptoms.
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Dkt. #11, p.701. Dr. Freitas declined plaintiff’s request for diazepam, explaining that
plaintiff’s chronic anxiety and panic disorder would be best treated by his primary care
physician or a psychiatrist. Dkt. #11, p.701.
Plaintiff underwent surgery for a fractured right tibia with associated fibular
fracture on December 9, 2015. Dkt. #11, p.703.
On May 18, 2016, Dr. Rozmus noted plaintiff’s failure to follow up with
referral for upper endoscopy to assess his complaints of chronic abdominal pain and
vomiting. Dkt. #11, p.585. He was also provided a referral for physical therapy following
his tibia fracture and prescribed Zoloft for chronic anxiety. Dkt. #11, p.585. Dr. Rozmus
declined to sign plaintiff’s disability forms absent a psychology evaluation. Dkt. #11,
p.585.
Dr. Chesnutt saw plaintiff intermittently between January 31, 2013 and
May 20, 2016 and continued to diagnose plaintiff with severe anxiety. Dkt. #11, p.613.
She noted “[m]any requests for me to complete forms; I stopped, since I had not seen
him nor was I treating him.” Dkt. #11, p.613.
On January 30, 2017, Dr. Chestnutt completed an assessment of plaintiff’s
functional limitations based upon the diagnostic testing conducted on January 31, 2013
and February 19, 2013, indicating that plaintiff was very limited in his ability to: carry out
instructions; maintain socially appropriate behavior without exhibiting behavior
extrements; and function in a work setting at a consistent pace. Dkt. #11, p.255. Dr.
Chestnutt also indicated that plaintiff was moderately limited in his ability to understand
and remember instructions; maintain attention/concentration; make simple decisions;
interact appropriately with others; and maintain basic standards of personal hygiene
and grooming. Dkt. #11, p.255. Dr. Chestnutt stated that her testing indicated that
plaintiff did have residual effects from his head injury and that she also found him to be
significantly disabled due to his anxiety. Dkt. #11, p.254. She reported that plaintiff has
been in treatment, trying medication to help him cope with his anxiety, but was unable
to find the right combination of medication to control his anxiety. Dkt. #11, p.254.
On April 11, 2018, PA-C Erin Sullivan noted that plaintiff was scattered in his
thoughts, which is his baseline, due to concussion. Dkt. #11, p.676. He denied nausea
or vomiting. Dkt. #11, p.673.
Plaintiff denied nausea or vomiting at a primary care visit on October 25,
2018 for infection after being scratched by a dog. Dkt. #11, p.562. He was observed to
have an appropriate mood, normal affect and thought process demonstrating
relevance. Dkt. #11, p.564.
On February 26, 2019, plaintiff denied nausea or vomiting but reported
overwhelming stress, sleep disturbances and anxiety. Dkt. #11, p.602. Kaitlyn Domres,
M.D., provided plaintiff with a referral to a new mental health provider. Dkt. #11, p.604.
Dr. Domres completed a Medical Examination for Employability Assessment, Disability
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Screening, and Alcoholism/Drug Addiction Determination Form for the New York State
Office of Temporary and Disability indicating that plaintiff was moderately limited in his
ability to walk, sit, lift, carry, push, pull, bend, climb stairs, make simple decisions,
maintain socially appropriate behavior without exhibiting behavior extremes and
function in a work setting at a consistent pace; moderately to very limited in his ability to
stand; and very limited in his ability to understand and remember instructions, carry out
instructions, and maintain attention and concentration. Dkt. #11, p.735.
On July 5, 2019, plaintiff reported weight loss as a result of reduced alcohol
intake, noting that he has been less anxious with reduced alcohol intake. Dkt. #11,
p.634. He declined medication for anxiety, stating that it does not work. Dkt. #11, p.634.
Dr. Domres provided plaintiff with referrals for mental health treatment and evaluation of
concussion syndrome. Dkt. #11, p.637.
Plaintiff reported overwhelming stress, sleep disturbance and anxiety on
October 2, 2019. Dkt. #11, p.663. He also reported that he had cut his drinking from 6-8
beers daily to 2-3 beers daily and had tried marijuana to help his anxiety. Dkt. #11,
p.663. Dr. Domres noted that plaintiff was seeing a counselor which has been helping
him significantly. Dkt. 311, p.666. Dr. Domres referred plaintiff to psychiatry for
completion of SSI paperwork. Dkt. #11, p.666.
On July 10, 2019, plaintiff denied nausea or vomiting to Dr. Domres. Dkt. #11,
p.630.
On July 31, 2019, John Leddy, M.D., a primary care sports medicine
physician specializing in evaluation and treatment of post-concussion syndrome,
evaluated plaintiff and observed him to be obviously quite anxious with some pressured
speech. Dkt. #11, p.11. Dr. Leddy opined that his symptoms were the result of anxiety
rather than his history of concussions. Dkt. #11, p.707. Dr. Leddy recommended
cognitive behavioral therapy. Dkt. #11, p.707.
On September 30, 2019 and November 4, 2019, Taryn Edmondson, LMHC,
at BestSelf Behavioral Health, provided a Medical Opinion Re: Ability To Do Work-
Related Activites (Cognitive), based on treatment since July 24, 2019 assessing plaintiff
to be seriously limited1 in his ability to maintain attention for two hour segments; work in
coordination with or proximity to others without being unduly distracted; complete a
normal workday and workweek without interruptions from psychologically based
symptoms; perform at consistent pace without an unreasonable number and length of
rest periods; accept instructions and respond appropriately to criticism from
supervisors; get along with co-workers or peers without unduly distracting them or
exhibiting behavioral extremes; respond appropriately to changes in a routine work
setting; deal with normal work stress; set realistic goals or make plans independently of
others; and maintain socially appropriate behavior. Dkt. #11, pp.777-779. Ms.
Edmondson explained that plaintiff has difficulty maintaining appropriate interpersonal
relationships due to trouble managing emotions, attention and time management. Dkt.
1 Seriously limited is defined as noticeable difficulty from 11-20% of the workday or
workweek. Dkt. #11, p.777.
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#11, p.778. She noted the following symptoms: impaired impulse control; generalized
persistent anxiety; mood disturbance; difficulty thinking or concentrating; recurrent and
intrusive recollections of a traumatic experience, which are a source of marked distress,
pathological dependence, passivity or agressivity; intense and unstable interpersonal
relationships and impulsive and damaging behavior; flight of ideas; inflated self-esteem;
and easy distractibility. Dkt. #11, p.780. Plaintiff was diagnosed with adjustment
disorder with anxiety, as well as narcissistic and histrionic tendencies. Dkt. #11, p.779.
Ms. Edmonson was unable to assess the effect of alcohol or substance abuse on
plaintiff’s symptoms as he had not completed a toxicology screening, but noted
continuing assessment to rule out alcohol related issues and bipolar disorder. Dkt. #11,
p.779 & 784.
On October 23, 2019, plaintiff underwent an integrated initial psychiatric
evaluation at BestSelf Behavioral Health, resulting in the following impression:
[Plaintiff] has a history of self-reported ADD/ADHD and trauma
exposure related to his previous employment in law enforcement
and exposure to violence. He reports impulsivity throughout his
childhood and into adulthood. His chief complaint is the severe
anxiety and panic he’s been experiencing since the breakup of a
longterm relationship. The information he discloses appears to be
inconsistent to prior assessments with counselor, and it is difficult to
obtain a detailed history.This could be due to his multiple head
injuries or as a result of his anxiety and preoccupation with recent
breakup. The patient expresses overvalued ideas around his
previous employment and past relationships with women. He
frequently interrupts writer to discuss his security clearance and
status in law enforcement. Cluster B traits cannot be excluded. His
past history of impulsivity and spending does leave concern for
Bipolar Disorder. This and substance use should be further
explored. [Plaintiff] denies any medication management at this time.
Dkt. #11, p.717.
The ALJ relied upon an unremarkable CT scan and reports of normal
neurological findings to find that plaintiff’s alleged neurological impairments, insomnia
and history of traumatic brain injury were not as severe as alleged. Dkt. #11, p.342.
Despite the diagnosis of anxiety, the ALJ found it “important to note that the record
generally lacks objective medical findings from mental health providers to corroborate
the alleged extent of the anxiety.” Dkt. #11, p.342. The ALJ further determined that the
lack of medication management and refusal to receive medication was inconsistent with
the alleged severity of plaintiff’s anxiety. Dkt. #11, p.343. She also noted his lack of
consistent treatment and substance use as evidence undermining the alleged intensity
and limiting effects of plaintiff’s psychiatric symptoms. Dkt. #11, p.343. The ALJ afforded
Dr. Chestnutt’s opinion little weight in light of the “generally normal psychiatric findings
reflected in the medical evidence, lack of consistent mental health treatment, non-
compliance and alcohol use.” Dkt. #11, p.344. The ALJ afforded Dr. Dorres’ opinion
some weight as it was supported with evidence throughout the record, including the
“generally normal psychiatric findings reflected in the medical evidence.” Dkt. #11, p.345.
The ALJ afforded Ms. Edmonson’s opinion very limited weight in light of the “generally
normal psychiatric findings reflected in the medical evidence, lack of consistent mental
health treatment, non-compliance and alcohol use.” Dkt. #11, p.345. The ALJ also found
the extent of the limitations identified by Ms. Edmonson unsupported by objective
medical evidence or plaintiff’s reported abilities. Dkt. #11, p.345.
The ALJ’s rejection of all of the medical source opinions is not supported
by substantial evidence, as is obvious from the exhaustive recitation of the medical
record set forth above. See Shamone W. v. Comm’r of Soc. Sec’y, 2021 WL 1015934, at
*6 (W.D.N.Y. Mar. 17, 2021) (rejecting ALJ’s formulation of an RFC that was completely
divorced from the assessments reflected in each of the opinions of record). Where, as
here, application of the correct legal standards to all of the relevant evidence, including
acceptable medical source opinion evidence and other source opinion evidence,
compels the conclusion that plaintiff is disabled, remand for calculation of benefits is
warranted. See Trumpower v. Colvin, 2015 WL 162991, at *18 (W.D.N.Y. Jan. 13, 2015)
(remanding for calculation of benefits based upon medical source opinion of Licensed
Master Social Worker).
CONCLUSION
Based on the foregoing, plaintiff’s motion for judgment on the pleadings (Dkt.
#16), is granted in so far as plaintiff seeks remand for further proceedings and the
Commissioner’s motion for judgment on the pleadings (Dkt. #18), is denied.
The Clerk of the Court is directed to close this case.
SO ORDERED.
DATED: Buffalo, New York
September 30, 2021
s/ H. Kenneth Schroeder, Jr.
H. KENNETH SCHROEDER, JR.
United States Magistrate Judge