Moran

UNITED STATES DISTRICT COURT

EASTERN DISTRICT OF NEW YORK

RAMON ANTONIO MORAN,

Plaintiff,

MEMORANDUM & ORDER

– against – 24-cv-08153 (NCM)

COMMISSIONER OF THE SOCIAL

SECURITY ADMINISTRATION,

Defendant.

NATASHA C. MERLE, United States District Judge:

Plaintiff Ramon Antonio Moran brings this action against defendant

Commissioner of the Social Security Administration (“Commissioner”) seeking judicial

review of the Commissioner’s decision on plaintiff’s application for disability insurance

benefits and supplemental social security income benefits. Compl. ¶¶ 1, 4, 6, 8, ECF No.

1. Before the Court is plaintiff’s motion for judgment on the pleadings (“Motion”), ECF

No. 10-1, and the Commissioner’s cross-motion for judgment on the pleadings (“Cross-

Motion”), ECF No. 12-1. For the reasons stated below, plaintiff’s Motion is GRANTED,

and the Commissioner’s Cross-Motion is DENIED.

BACKGROUND

I. Factual Background

Plaintiff is a middle-aged man from the Dominican Republic. See R. 60, ECF No.

7; see also Joint Stipulation of Relevant Facts (“Joint Stip.”) ¶ 45, ECF No. 14.1 Plaintiff

1 Throughout this Order, page numbers for the Certified Administrative Record

(“R.”) refer to the numbers found in the bottom right corner of each page, rather than the

moved to the United States and worked in maintenance and as an airplane cleaner from

1994 to October 2016. R. 60, 251; see also Joint Stip. ¶ 45. On October 24, 2016, plaintiff

went to an emergency room seeking treatment for neck pain, fever, nausea, frequent

headaches, and knee pain. Joint Stip. ¶ 2. Two weeks later plaintiff returned to the

emergency room seeking treatment “for generalized weakness and left knee pain over the

previous few weeks.” Joint Stip. ¶ 3. Hospital staff conducted an electrocardiogram

(“EKG”) that showed plaintiff had a rapid heart rate and an abnormal white blood cell

count, but staff otherwise did not detect any infectious diseases. Joint Stip. ¶ 3. On

November 16, 2016, plaintiff visited his primary care physician with complaints of fatigue,

general weakness, knee pain, and malaise. Joint Stip. ¶ 4. Plaintiff’s physician detected

that plaintiff’s blood pressure was very low and that he had jaundice, so plaintiff was sent

to the emergency department. Joint Stip. ¶ 4.

Upon admittance to the emergency department, plaintiff was diagnosed with

sepsis. Joint Stip. ¶ 4. Diagnostic tests showed that plaintiff had several infections,

blockages, and severe damage in his brain, heart, and lungs. See Joint Stip. ¶ 4. A few days

after being admitted plaintiff was diagnosed with, among other things, mitral valve

endocarditis, “an infection of the heart [that] can cause rapid, severe damage to the heart

valves.” Joint Stip. ¶ 5 n.11. On November 29, 2016, plaintiff underwent open-heart

surgery, which involved the replacement of two heart valves. Joint Stip. ¶ 7. Following the

procedure plaintiff was diagnosed with “aortic valve and mitral valve disease, severe

mitral insufficiency, and endocarditis.” Joint Stip. ¶ 7.

page numbers assigned by the Electronic Case Filing system (“ECF”). All other page

numbers for docket filings refer to the page numbers assigned by ECF.

Plaintiff was discharged from the hospital about one week later. Around that time,

plaintiff’s cardiac surgeon provided a letter stating that plaintiff was “unable to return to

work at th[at] time” due to his extensive hospital stay and cardiac surgery. Joint Stip.

¶¶ 10–11; see also R. 600. Plaintiff was seen in a cardiology clinic shortly thereafter where

he “denied chest pain, shortness of breath, palpitation, lightheadedness, headaches, and

dizziness,” but nevertheless was prescribed oxycodone to alleviate discomfort. Joint Stip.

¶ 12.

Then, on February 6, 2017, plaintiff underwent a thoracic endovascular aortic

repair (“TEVAR”) procedure. Joint Stip. ¶ 13. However, the TEVAR procedure led to

complications, specifically, insufficient blood flow to plaintiff’s organs and legs. Joint

Stip. ¶ 13. This necessitated open fenestration surgery—a “more invasive, open-chest

surgery” used as an alternative to TEVAR—to restore blood flow. Joint Stip. ¶ 13 n.23.

During this procedure surgeons discovered a “new Type A aortic dissection,” i.e., a tear in

the inner layer of the aorta—but “further surgery was halted as the surgeons estimated

plaintiff would not tolerate major aortic surgery.” Joint Stip. ¶ 13. Instead, surgeons

“packed” the wound, and plaintiff was transferred to the intensive care unit (“ICU”) in

critical condition. Joint Stip. ¶ 13.

II. Medical Evidence

Relevant to the parties’ current dispute, the administrative record of plaintiff’s

benefits proceedings includes two consultative examinations conducted in connection

with plaintiff’s disability application, as well as testimony from plaintiff and a medical

expert at hearings before the Administrative Law Judge (“ALJ”).

A. Consultative Examinations

1. Dr. Paulvin’s Report

On February 24, 2017, a few weeks after plaintiff’s second heart surgery, plaintiff

was evaluated by Dr. Paulvin, a consultative examiner who specialized in family medicine.

Joint Stip. ¶ 14; see also R. 606. The report notes that plaintiff suffered from hypertension

since 2005, and that plaintiff had “surgery on an infection in his valve done in November

2016.” R. 606. In the “past history” section of the report, Dr. Paulvin indicates that

plaintiff “was hospitalized in November 2016 at New York Presbyterian Hospital for the

cardiac surgery.” R. 606. The report does not mention the February 2017 surgery and

emergency hospitalization. See R. 606–08.

The report indicates that plaintiff’s prognosis was “good.” R. 608. Dr. Paulvin

opined that plaintiff was “limited just by the pain he has when he lifts, secondary to his

surgery,” but that such pain was “not reproducible.” R. 608. The report further states that

plaintiff denied chest pain or shortness of breath, and that plaintiff’s “[p]ulmonary,

abdominal, neurologic and musculoskeletal findings were all normal.” Joint Stip. ¶ 14.

Dr. Paulvin further noted that plaintiff was able to cook, shop, shower, and dress himself,

but that he could not clean or do laundry due to problems with bending and pain from his

surgery. Joint Stip. ¶ 14.

2. Dr. Meisel’s Report

Dr. Allen Meisel, another consultative examiner for the SSA, evaluated plaintiff on

July 31, 2018. Dr. Meisel’s report also indicated that plaintiff was hospitalized in 2016,

because he “apparently had endocarditis.” R. 1884. Dr. Meisel noted that plaintiff had an

aortic valve replacement in November 2016, but—just like Dr. Paulvin’s report—omitted

any mention of the February 2017 surgery. See R. 1884–87. Dr. Meisel opined that

plaintiff’s prognosis was “fair.” R. 1886. Dr. Meisel further opined that plaintiff had

“marked limitations of heavy lifting and carrying,” as well as “climbing ladders, scaffolds,

and being exposed to unprotected heights.” R. 1886. The report indicated that “[b]ecause

of [plaintiff’s] cardiac status[,] [h]e should avoid activities which are mildly or moderately

strenuous.” R. 1886. Dr. Meisel also noted that plaintiff had limitations with standing,

walking, bending, kneeling, and climbing. R. 1886.

B. Testimony

1. Plaintiff’s Testimony

At a hearing before the ALJ on March 13, 2019, plaintiff testified that he worked

various jobs in maintenance and janitorial work prior to his first heart surgery. R. 29–30.

Plaintiff testified that for the five months following surgery, nurses would come to his

house to give him antibiotics to treat his sepsis. See R. 32. Although plaintiff testified that

his condition gradually improved, he also testified that he had significant chest pain from

the surgery. See R. 32–33. Specifically, plaintiff testified that on a scale of zero to ten, with

ten “being the worst pain in the world,” his pain “was at 10” at the incision point from his

surgery. R. 33. Plaintiff explained that this pain slowly subsided, but it did not go away

until “March or February of 2018.” R. 33–34. Plaintiff further testified that, as of the date

of the hearing, he could not stand for long periods of time, and that he believed his

difficulties standing stemmed from his heart problems. R. 35.

Plaintiff testified again at a November 9, 2022 hearing before the ALJ. Plaintiff

testified that he had “numbness” in his legs since his surgery. R. 1942. The ALJ asked

plaintiff’s counsel at the hearing, Mr. Farhi, whether there were any clinical reports

reflecting leg numbness in the record, which led to the following exchange:

ALJ: Yes. Is it any place in the clinical records, is what I’m

looking for, sir?

FARHI: Very well. Was we -- clinical records are sparse, shall

we say, on this case. But I think (INAUDIBLE) is that

assessment.

ALJ: Sparse? Sparse? There’s 1,796 pages. Do you consider

that sparse evidence, Mr. Farhi?

FARHI: Excuse me?

ALJ: You said the medical evidence is sparse. There’s 1,796

pages.

FARHI: Well, he has a very serious heart condition. And he

went through a lot of procedures in 2017.

ALJ: 2016.

FARHI: Since then, I don’t know how –

ALJ: 2016, sir.

FARHI: 2016.

ALJ: Yes, Sir.

FARHI: Well, the operation --

ALJ: But anyway, it’s your witness. If you think the record is

sparse — you think it’s sparse. I think 1,700 pages is pretty

significant. But please go ahead. You may continue asking

your questions to the claimant.

R. 1944–45.

Following this exchange, plaintiff testified that it took approximately one year and

four months to recover from his February 2017 surgery. R 1946. He explained that

although some people heal quickly following open-heart surgery, in his case, “it took a

while for [him] to recover.” R. 1947. Plaintiff also explained that his doctors instructed

him not to lift anything heavy. See R. 1948–49. Plaintiff was asked whether he might need

another surgery given that his second surgery was aborted, and he was in severe condition

at the time, but plaintiff testified that he did not know if he needed another surgery

because his doctor “had not told [him] anything yet.” R. 1948.

C. Dr. Jilhewar Testimony

At the March 2019 hearing, Dr. Ashok Jilhewar testified as a medical expert. R. 38.

Dr. Jilhewar testified that he was board certified in internal medicine and

gastroenterology, and that he had treated patients with severe heart conditions, “but not

one like [plaintiff].” R. 38. Dr. Jilhewar then testified as to his review of the medical

records in the case. Specifically, he recounted the events leading up to plaintiff’s first

open-heart surgery in November 2016. R. 40–42. Dr. Jilhewar explained that shortly

after plaintiff was discharged from the hospital, he “developed dissection of aorta . . . in

the chest cavity.” R. 42. Relying on the operating report from the February 6, 2017

procedure in the record, Dr. Jilhewar observed that plaintiff “required second surgery to

try to correct the effects” of the dissection of the aorta, but that “post-operative recovery

was . . . uneventful” because Dr. Paulvin’s report indicated that plaintiff “recovered by the

time of consultative examination.” R. 42–43. Dr. Jilhewar opined that plaintiff had a

“sedentary” residual functional capacity (“RFC”) once he recovered from his surgery.

Joint Stip. ¶ 50; see also R. 43.

Dr. Jilhewar also testified as to plaintiff’s recovery from the surgeries. Specifically,

he testified that at the time of the hearing plaintiff had “recovered except for the pain at

the site of the incision.” R. 43. He explained that it normally takes six months to recover

from a heart operation like plaintiff underwent, but that he could not confirm plaintiff’s

recovery timeline because he “did not find . . . documentation of the cardiac rehab” in the

record. R. 44. The ALJ asked Dr. Jilhewar whether there was any indication that plaintiff

suffered “any sort of chest pain that might prevent work activity[.]” R. 45. Dr. Jilhewar

explained that he would “expect” that one year after the second surgery plaintiff “should

be able to do . . . light physical work unless documented.” R. 46. However, Dr. Jilhewar

noted that he did “not have . . . documentation one year after the second surgery.” R. 45.

After the ALJ’s questioning, plaintiff’s counsel asked Dr. Jilhewar questions

pertaining to plaintiff’s condition and recovery. Notably, when asked about plaintiff’s

heart disorders and the nature of his surgeries, Dr. Jilhewar testified: “[T]he operation

was very extensive, life-threatening, and [plaintiff] has recovered miraculously, much

more faster [sic] than I would have expected.” R. 50. He further testified that a

hypothetical person who went through plaintiff’s procedure would be expected to have

post-traumatic stress disorder, but Dr. Jilhewar did “not have documentation” to confirm

as such in plaintiff’s case. R. 50.

III. Procedural Background

Plaintiff applied for disability insurance and supplemental security income

benefits on January 27, 2017. R. 212. Plaintiff listed eight conditions as the basis for his

application: (1) presence of [a] prosthetic heart valve; (2) bacteremia; (3) sepsis; (4)

s[ep]tic arterial embolism; (5) nontraumatic mitral; (6) subarachnoid hemorrhage; (7)

high blood pressure; and (8) hypertension. R. 251. The ALJ held a hearing on March 13,

2019, at which plaintiff; Dr. Jilhewar—a medical expert; and a vocational expert testified.

Joint Stip. 1. By decision dated May 30, 2019, the ALJ found that plaintiff was not disabled

for purposes of SSA regulations. Joint Stip. 1. The ALJ concluded that although plaintiff

“had been very ill, . . . his condition did not last the required 12-month period to establish

disability, and by July 2017, [plaintiff] could perform basic work activities.” R. 92.

Plaintiff requested and was granted review of the ALJ’s decision by the SSA Appeals

Council. Joint Stip. 1. The Appeals Council found that there was an error of law in the

ALJ’s decision, specifically because the ALJ had “requested and received [a] consultative

examination report prior to the scheduled hearing and it was not exhibited or entered into

the record.” R. 206. The Appeals Council also concluded, contrary to the ALJ’s conclusion,

that plaintiff’s “history of endocarditis status post heart surgery was a severe

impairment.” R. 207. Nevertheless, the Appeals Council adopted the ALJ’s determination

of plaintiff’s RFC and thus concurred that plaintiff was not disabled for purposes of the

Social Security Act. See R. 207.

Plaintiff appealed the decision to this district on November 3, 2020. Joint Stip. 1;

see also Moran v. Comm’r of Soc. Sec., No. 20-cv-05313 (E.D.N.Y. filed Nov. 3, 2020). By

joint stipulation the parties agreed to reverse and remand the ALJ’s decision on the

grounds that the ALJ “did not properly consider the evidence in finding that [p]laintiff

was not disabled within the meaning of the Social Security Act.” Moran, ECF No. 22-1 at

1. The parties agreed that on remand defendant would, among other things, “offer

[p]laintiff the opportunity for a new hearing, take further action to complete the

administrative record, and issue a new decision.” Moran, ECF No. 22-1 at 1.

On remand, the same ALJ held hearings on August 11, 2022, and November 9,

2022. Joint Stip. 2. Plaintiff and another vocational expert testified. Joint Stip. 2. By

decision dated December 5, 2022, the ALJ issued a partially favorable decision, finding

that plaintiff was disabled on October 14, 2022, “the day his age category changed to an

individual of advanced aged,” but also finding that plaintiff was not disabled prior to that

date. Joint Stip. 2. The Appeals Council affirmed the ALJ’s decision on September 26,

2024, and plaintiff filed the instant appeal on November 25, 2024. Compl. ¶ 7.

STANDARD OF REVIEW

A district court reviewing a final decision of the Commissioner is empowered “to

enter, upon the pleadings and transcript of the record, a judgment affirming, modifying,

or reversing the decision of the Commissioner of Social Security, with or without

remanding the cause for a rehearing.” 42 U.S.C. § 405(g); see Fed. R. Civ. P. 12(c)

(allowing courts to enter a judgment on the pleadings). Nonetheless, federal judicial

review is “limited.” Rubin v. Martin O’Malley, Comm’r of Soc. Sec., 116 F.4th 145, 154 (2d

Cir. 2024).2 Reviewing courts “do not substitute” their own “judgment for the agency’s”

or review the record de novo. Cage v. Comm’r of Soc. Sec., 692 F.3d 118, 122 (2d Cir.

2012). Instead, “[w]e conduct a plenary review of the administrative record to determine

if there is substantial evidence, considering the record as a whole, to support the

Commissioner’s decision and if the correct legal standards have been applied.” Rubin, 116

F.4th at 154.

In conducting this review, courts must determine (1) “whether the correct legal

standards were applied,” and (2) “whether substantial evidence supports the decision.”

Butts v. Barnhart, 388 F.3d 377, 384 (2d Cir. 2004), as amended on reh’g in part, 416

F.3d 101 (2d Cir. 2005); see also Rucker v. Kijakazi, 48 F.4th 86, 90–91 (2d Cir. 2022).

Whether the record contains “substantial evidence” depends on whether “a reasonable

mind might accept” the evidence “as adequate to support” the ALJ’s determination.

Biestek v. Berryhill, 587 U.S. 97, 102–03 (2019) (explaining that “[t]he phrase

‘substantial evidence’ is a ‘term of art’ used throughout administrative law to describe how

2 Throughout this Order, the Court omits all internal quotation marks, footnotes,

and citations, and adopts all alterations, unless otherwise indicated.

courts are to review agency factfinding”). The “threshold for such evidentiary sufficiency

is not high”; it requires only that the record contain “more than a mere scintilla” of

evidence. Id. at 103. The court must uphold the Commissioner’s conclusion so long as it

is supported by a “rational interpretation” of the evidence. Rubin, 116 F.4th at 155.

However, courts must still “examine contradictory evidence and evidence from which

conflicting inferences can be drawn.” Id.

“Before determining whether the Commissioner’s final decision is supported by

substantial evidence[,] the court must first be satisfied that the ALJ completely developed

the administrative record.” Kelly v. Comm’r of Soc. Sec., No. 20-cv-05318, 2024 WL

5120051, at *9 (E.D.N.Y. Dec. 16, 2024). The ALJ has a “well-established” obligation to

investigate and develop the record, even where a claimant is counseled—this “has been

described as a bedrock principle of Social Security law.” Id. Accordingly, where the

presiding ALJ did not apply the correct legal standard or sufficiently develop the record,

a court may remand the case for further proceedings. See Sczepanski v. Saul, 946 F.3d

152, 162 (2d Cir. 2020); Daniels v. Kijakazi, 617 F. Supp. 3d 180, 195 (S.D.N.Y. 2022).

DISCUSSION

I. Statutory and Regulatory Disability Benefit Requirements

The SSA administers social security disability insurance benefits to eligible

applicants pursuant to the Social Security Act. See generally 42 U.S.C. § 301 et. seq. To

secure benefits, an applicant must demonstrate, among other things, that he is disabled:

that his impairment or combination of impairments renders him unable “to engage in any

substantial gainful activity by reason of any medically determinable physical or mental

impairment which can be expected to result in death or which has lasted or can be

expected to last for a continuous period of not less than 12 months.”

42 U.S.C. § 423(d)(1)(A). The Commissioner, acting through a presiding ALJ, assesses

whether an applicant meets the statutory definition of disabled by undertaking a “five-

step sequential evaluation process.” 20 C.F.R. § 404.1520(a)(4). The Commissioner only

advances to the next step where a determination of an applicant’s disability status cannot

be made at that stage. Id.

The first step is to evaluate the applicant’s work activity; a disability determination

will be denied where an applicant is engaged in substantial gainful activity. 20 C.F.R.

§ 404.1520(a)(4)(i). At the second step, the Commissioner “considers the medical severity

of the claimant’s impairment or combined impairments.” Rubin, 116 F.4th at 147 (citing

20 C.F.R. § 404.1520(a)(4)(ii)). The third step is a determination on whether the

applicant’s impairments “meets or equals” one of the listings in Appendix 1 of Part 404,

Subpart P (“Subpart Listed Impairment”). 20 C.F.R. § 404.1520(a)(4)(iii). If the

applicant’s impairments do not meet or equal a Listed Impairment, the Commissioner

determines the claimant’s RFC, which is the claimant’s ability to function in a workplace

despite medical limitations and “based on all the relevant medical and other evidence in

[the] case record.” 20 C.F.R. § 404.1520(e). At step four, the Commissioner assesses

whether the claimant can perform past relevant work when considering the claimant’s

RFC. 20 C.F.R. § 404.1520(a)(4)(iv).

If the claimant cannot perform his past relevant work, the fifth and final step is to

consider whether an applicant, given his RFC, age, education, and work experience, can

perform other work. 20 C.F.R. § 404.1520(a)(4)(v). The claimant “bears the burden of

proof in the first four steps of the sequential inquiry.” Selian v. Astrue, 708 F.3d 409, 418

(2d Cir. 2013). However, at step five, “the burden shifts, to a limited extent, to the

Commissioner to show that other work exists in significant numbers in the national

economy that the claimant can do.” Rubin, 116 F.4th at 148.

II. The ALJ’s Determination

At step one, the ALJ found that plaintiff had not engaged in substantial gainful

activity since September 30, 2016. R. 1914. At step two, the ALJ found that plaintiff

suffered from two medically severe impairments: endocarditis stats post-surgery and

obesity. R. 1914. The ALJ also noted that plaintiff was diagnosed with hypertension and

suffered from high cholesterol and tension headaches, although none of these conditions

amounted to medically severe impairments. R. 1914. At step three, the ALJ concluded that

plaintiff’s obesity and endocarditis did not meet or equal the severity of a Subpart Listed

Impairment. R. 1914. In reaching this conclusion the ALJ “gave particular attention” to

the cardiovascular system impairment included as a Subpart Listed Impairment, R. 1915;

see Subpart Listed Impartment 4.00, but reasoned that plaintiff’s “impairments were not

severe enough, for long enough, to meet or medically equal any listing,” R. 1915. The ALJ

reasoned that plaintiff was “very ill from October 2016 through February 2017, but by

July 2017 he was stable.” R. 1915. Therefore, in the ALJ’s view, plaintiff “did not have

significant symptoms, approaching [a Subpart Listed Impairment] level, for a period of

at least 12 continuous months.” R. 1915.

The ALJ then assessed plaintiff’s RFC and concluded that plaintiff had the RFC to

“perform light work,” except that plaintiff could only occasionally “stoop, kneel, crouch,

and crawl.” R. 1915. The ALJ found that plaintiff could not reach overhead but could reach

at a desk. R. 1915. The ALJ opined that plaintiff should be “expected to be off task 9% of

the workday.” R. 1915. In reaching these findings the ALJ explained that she must follow

a two-step process in which she first was required to determine if there was an “underlying

medically determinable physical or mental impairment(s)” that could “reasonably be

expected” to produce plaintiff’s pain or other symptoms. R. 1915. Then, at step two of the

process, the ALJ stated that she was required to evaluate the “intensity, persistence, and

limiting effects” of plaintiff’s symptoms to ascertain how those symptoms impacted

plaintiff’s work-related activities. R. 1915. In doing so, the ALJ noted that if statements

about the limiting effects of plaintiff’s pain and other symptoms were not “substantiated

by objective medical evidence,” then she must “consider other evidence in the record to

determine if [plaintiff’s] symptoms limit the ability to do work-related activities.” R. 1915.

The ALJ concluded at step one that plaintiff did have medically determinable

impairments that could reasonably be expected to cause some of the alleged symptoms.

R. 1916. However, at step two, the ALJ found that plaintiff’s statements concerning the

limiting effects of his symptoms were “inconsistent” and were “not fully supported by the

medical evidence” in the record. R. 1916. The ALJ also opined that plaintiff’s allegations

concerning his symptoms were “not fully in line” with his “reported activities of daily

living.” R. 1916. The ALJ compared plaintiff’s statements concerning his pain, symptoms,

and activities of daily living as set forth in his disability application with medical evidence

in the record. R. 1915–16 (citing R. 250, 258). The ALJ turned to a series of hospital and

medical examination records spanning from October 24, 2016 through January 20, 2022

and found that “[i]t [wa]s clear that from October 2016 through February 2017, the

claimant was very ill[,]” but that “by July 19, 2017, the claimant was feeling better and

was stable.” R. 1916. Additionally, the ALJ weighed various medical opinion evidence in

the record, including evidence from plaintiff’s treating physician, the Commission’s

independent consultative examiners, and medical expert testimony at the November 2019

hearing. R. 1917–18.

The ALJ reasoned that the record evidence supported the conclusion that plaintiff

had the RFC to perform light work with certain limitations. R. 1919. The ALJ noted that

her conclusion regarding plaintiff’s RFC “t[ook] into account [plaintiff’s] heart disease by

limiting him to light work with no overhead lifting.” R. 1919. The ALJ also explained that

she accounted for plaintiff’s reports of dizziness, headaches, and shortness of breath by

“limiting [plaintiff] from working at heights or ladders,” as well as plaintiff’s “[o]ff-task

limitation.” R. 1919.

At step four, the ALJ concluded that plaintiff’s RFC did not permit him to perform

his past relevant work as a janitor, airplane cleaner, and industrial cleaner. R. 1919; see

also Joint Stip. 3. At step five, the ALJ found that beginning on October 14, 2022—when

plaintiff turned fifty and his age category for purposes of SSA regulations changed to an

individual of advanced age—no jobs existed in significant numbers in the national

economy that plaintiff could perform based on his age, education, work experience, and

RFC. R. 1919–21, see Joint Stip. 3. However, the ALJ concluded that prior to October 14,

2022—when plaintiff was in a younger age category—there were jobs that plaintiff could

perform. Relying on the testimony of the vocational expert, the ALJ determined that

plaintiff could perform jobs such has a produce weigher, collator, small products

assembler, and line service attendant. R. 1920–21. Thus, the ALJ reasoned that plaintiff

“was not disabled prior to October 14, 2022, [but] became disabled on that date” for

purposes of the Social Security Act. R. 1921–22.

III. The Court’s Analysis of the ALJ’s Determination

Plaintiff appeals the ALJ’s decision on several grounds. As a threshold matter,

plaintiff asserts that the ALJ failed to fully develop the record. Mot. 12. In particular,

plaintiff notes that the there is only a single document—the operating report—in the

record reflecting plaintiff’s emergency heart surgery in February 2017. Mot. 12. Plaintiff

notes that this surgery was “aborted,” and that he was “transferred to the ICU in critical

condition to await another open-heart surgery.” Mot. 12. Yet, according to plaintiff,

“[t]here are no other records of this hospitalization,” thus amounting to a “glaring gap in

the evidentiary record.” Mot. 12. Next, plaintiff argues that the ALJ misapplied the legal

standard when evaluating plaintiff’s statements concerning the intensity, persistence, and

limiting effects of his symptoms. Mot. 7–12. Specifically, plaintiff argues that the ALJ did

not carry out the proper analysis in conducting the two-step credibility inquiry, including

because she failed to “clearly articulate[]” any “specific reasons” why plaintiff’s statements

concerning his symptoms were unsupported or otherwise inconsistent with his activities

of daily living. Mot. 12 (quoting Castel v. Saul, No. 19-cv-05180, 2020 WL 5775668, at

*19 (S.D.N.Y. Sep. 1, 2020)). Finally, even based on the evidence in the record, plaintiff

contends that the ALJ still erred because (1) she failed to properly evaluate the medical

opinion evidence, Mot. 16; (2) her RFC finding was not supported by substantial evidence,

Mot. 22; and (3) she improperly relied on the vocational expert’s testimony, Mot. 25.

A. Developing the Record

“[T]he ALJ generally has an affirmative obligation to develop the administrative

record.” Perez v. Chater, 77 F.3d 41, 47 (2d Cir. 1996). This duty “arises from the

Commissioner’s regulatory obligations to develop a complete medical record before

making a disability determination[.]” Pratts v. Chater, 94 F.3d 34, 37 (2d Cir. 1996)

(citing 20 C.F.R. § 404.1512(d)–(f) (1995)); see also Morris v. Berryhill, 721 F. App’x 25,

27 (2d Cir. 2018) (summary order) (“The social security ALJ, unlike a judge in a trial,

must on behalf of all claimants affirmatively develop the record in light of the essentially

non-adversarial nature of a benefits proceeding.”). Although this duty is heightened when

a claimant proceeds pro se, it “exists even when, as here, the claimant is represented by

counsel.” Pratts, 94 F.3d at 37. While it is true that the affirmative duty to expand the

record does not extend ad infinitum, reasonable efforts must be made to seek out further

information where evidentiary gaps exist, or where the evidence is inconsistent or

contradictory. Cadet v. Colvin, 121 F. Supp. 3d 317, 320 (W.D.N.Y. 2015).

Plaintiff contends that the ALJ did not attempt to “fill the[] gaps in the evidentiary

record” related to plaintiff’s rehab following his second heart surgery. Mot. 13. Despite

numerous documents in the record about plaintiff’s first heart surgery in November 2016,

the operative report of the February 2017 procedure is “the only document of that event

in the record.” Mot. 12. Moreover, “no other records” reflect that this procedure was

aborted, and that plaintiff was hospitalized shortly thereafter in critical condition. See

Mot. 12. Plaintiff notes that the consultative examiners and medical expert who opined

on plaintiff’s medical condition were seemingly either unaware of the second surgery and

hospitalization or indicated that they “would have liked to see treatment notes” following

the second surgery “to better evaluate the situation.” Mot. 12–13. Plaintiff attempted to

point out to the ALJ that records covering this period of his rehab were “sparse.” Mot. 13.

However, “the ALJ expressed skepticism because the record was, at the time, over 1700

pages.” Mot. 13 (citing R. 1944). Plaintiff argues that this failure was particularly

prejudicial because “the lack of records from [plaintiff’s] cardiac rehabilitation after his

February 2017 surgeries ma[d]e it difficult to evaluate” whether plaintiff had a Subpart

Listed Impairment. Mot. 14. That is, in the absence of the rehab records, the ALJ was

unable to determine if plaintiff was statutorily disabled. See Mot. 14–15.

Defendant disputes plaintiff’s characterization of the proceedings below and the

factual record on multiple fronts. First, defendant argues that plaintiff’s reliance on the

2019 hearing to suggest that the record was incomplete is “disingenuous.” Cross-Mot. 14.

Defendant points out that after that hearing plaintiff submitted almost 200 pages of

medical records, some of which included “additional cardiac findings from [plaintiff’s]

own doctors” that supported the ALJ’s conclusion as to plaintiff’s condition. Cross-Mot.

14. In a similar vein, defendant contends that plaintiff submitted a supplemental brief

prior to the November 2022 hearing, but plaintiff did not “mention[] any outstanding

records or suggest[] that further evidentiary development was needed.” Cross-Mot. 15.

Relatedly, defendant raises arguments pertaining to plaintiff’s representation during the

proceedings, including that (1) plaintiff’s counsel below “represented [that] the record

was complete” during the November 2022 hearing; and (2) to the extent that further

record development was needed, “the time to raise that issue was before the ALJ; counsel

cannot let the issue pass [and] see what the result of the hearing is, and then raise the

issue when the decision turns out to be adverse.” Cross-Mot. 18–19 (quoting Richard R.

v. Comm’r of Soc. Sec., No. 23-cv-06346, 2024 WL 4064084, at *5 (W.D.N.Y. Sept. 5,

2024)). Defendant further argues that any failure to develop the factual record was not

prejudicial because (i) plaintiff only “speculates that there are additional treatment notes

that were not part of the record,” Cross-Mot. 15; and (ii) any additional records about the

February 2017 surgery “would be of negligible probative value” because the ALJ

“acknowledged that [p]laintiff was very ill during this period.” Cross-Mot. 18. These

arguments are unavailing.

To begin, defendant’s suggestion that plaintiff conceded that the record was

complete based on counsel’s representations during the underlying benefit hearing is

without merit. An ALJ’s obligation to develop the record arises from the “non-adversarial

nature” of benefits proceedings. Lamay v. Comm’r of Soc. Sec., 562 F.3d 503, 508–09

(2d Cir. 2009). Thus, “[i]t is the ALJ’s duty to investigate and develop the facts and

develop the arguments both for and against the granting of benefits.” Butts, 388 F.3d at

386. As such, an ALJ’s “affirmative obligation to develop the record . . . cannot be relieved

. . . by a statement of counsel.” Santoro v. Comm’r of Soc. Sec., 703 F. Supp. 3d 376, 388

n.6 (E.D.N.Y. 2023); see also Francis v. Comm’r of Soc. Sec., No. 20-cv-04619, 2021 WL

3129873, at *3 (E.D.N.Y. July 23, 2021) (“[A] claimant’s representation by counsel before

the ALJ does not absolve the ALJ of his obligation to develop the record.”). Therefore, the

fact that plaintiff’s counsel “represented that the record was complete[,]” Cross-Mot. 15,

at the beginning of the November 2022 hearing did not relieve the ALJ of her duty to

develop the record. This is particularly so given that counsel attempted to explain that

there were “sparse” clinical records about the February 2017 surgery later during that

same hearing. See R. 1944; see also Santoro, 703 F. Supp. 3d at 388 n.6 (rejecting

Commissioner’s argument that the claimant’s attorney’s “agree[ment] that the record was

complete” relieved the ALJ of the duty to develop the record where “that statement came

at the very beginning of the hearing . . . before the attorney raised” issues with the record).

Next, defendant asserts that plaintiff’s reliance on the March 2019 hearing to

support his argument that the record was incomplete is “disingenuous” because plaintiff

“subsequently submitted nearly 200 pages of medical records.” See Cross-Mot. 14. The

Court disagrees. To be sure, plaintiff did submit additional medical records in connection

with his supplemental brief in advance of the November 2022 hearing, see R. 2213–2419,

some of which the ALJ relied on in support of her conclusion that plaintiff was not

disabled for purposes of the SSA, see R. 1917. But as plaintiff argues, those records

document plaintiff’s treatment years after his February 2017 surgery and thus “d[o] not

fill the lack [of records] identified by the [medical expert], nor include records of

Mr. Moran’s surgery for his second Type A aortic dissection.” Reply 4; see also R. 2228,

2297, 2298, 2325, 2335. More importantly, the supplemental records did not discharge

the ALJ of her duty to develop the factual record because that duty not only obligates an

ALJ to obtain medical records, but also to “obtain[] a consultative examination, re-

contact[] a medical source, or hav[e] an expert testify at the hearing” where necessary to

complete the record and afford the claimant a full and fair hearing. Golden v. Saul, No.

18-cv-06803, 2020 WL 3248821, at *6 (W.D.N.Y. June 16, 2020); see also Estella v.

Berryhill, No. 15-cv-06966, 2017 WL 2693722, at *22 (S.D.N.Y. June 22, 2017)

(explaining that the requirement that a benefit hearing be “full and fair . . . is derived from

the ALJ’s affirmative duty to develop the record”); accord Sarago v. Shalala, 884 F. Supp.

100, 105 (W.D.N.Y. 1995) (“[I]n order to ensure that a claimant” for social security

disability benefits has a fair hearing, the decisionmaker “incurs a general obligation

affirmatively to develop the record to ensure that all the necessary and relevant

information is produced”).

Further factual development is required here. On numerous occasions in the

proceedings below, plaintiff requested that the ALJ order an additional consultative

examination by, or testimony from, a cardiologist expert specifically because the other

consultative experts who opined on plaintiff’s RFC were seemingly unaware of plaintiff’s

second open-heart surgery. See R. 1940, 2217, 2219. The ALJ rejected these requests

because she found it sufficient that the testifying medical expert had considered the

February 2017 operative report, and noted that plaintiff “had the full opportunity to

question [the expert] at th[e] hearing.” R. 1941; see also R. 1912 (“The claimant’s request

for a medical expert is denied. There was a medical expert . . . called at the hearing held

on March 13, 2019. The doctor reviewed Exhibit 4F along with the other evidence in the

file at that time and counsel had a full opportunity to examine the doctor.”). But as the

medical expert himself testified, his opinions were based (i) on a limited record, see R. 44

(testifying that he could not “find the documentation of the cardiac rehab” following

plaintiff’s second operation); R. 45 (“I do not have a documentation one year after the

second surgery.”); and (ii) on the opinions in the record from consultative experts who—

as previously discussed—were unaware of the second surgery, see R. 42–43 (relying on

consultative examination to opine that plaintiff’s “post-operative recovery was . . .

uneventful, and [plaintiff] recovered by the time of consultative examination”).

For this reason, defendant’s argument that additional records concerning the

second emergency heart surgery “would be of negligible probative value” fails to move the

needle. Cross-Mot. 18. Defendant argues that any gaps in the record related to plaintiff’s

second surgery would be harmless because other evidence indicated that plaintiff had

recovered and was stable from his second surgery by, at the latest, July 2017. See Cross-

Mot. 18; see also R. 48. And because the ALJ concluded that plaintiff “was very ill”

beginning in October 2016, R. 1916, any records concerning plaintiff’s symptoms in the

intervening months would be of “negligible” value to the ALJ’s overall disability

determination. That is, because the ALJ concluded that plaintiff recovered by July 2017,

plaintiff could not establish a continuous 12-month period of limitation for disability

purposes regardless of his condition immediately after the second surgery, and thus “it is

not relevant how limited [p]laintiff was during and after the hospitalizations[.]” Cross-

Mot. 18.

But this argument fails to account for the fact that the ALJ was required to consider

both medical evidence and plaintiff’s “statements about the intensity, persistence, and

limiting effects of [his] symptoms” in her disability determination. Sabellico v. Comm’r

of Soc. Sec., No. 21-cv-02777, 2023 WL 6214214, at *5 (E.D.N.Y. Sep. 25, 2023). In doing

so, the ALJ weighed the credibility of plaintiff’s statements about his symptoms—

including that he suffered severe chest pain for more than a year after his second surgery.

See R. 33. The ALJ concluded that those statements were “not fully supported” by the

record, R. 1916, a record that contained essentially no documentation concerning

plaintiff’s second heart surgery, and included the opinions of two consultative examiners

who were unaware of an operation plaintiff underwent which the testifying medical

examiner described as “very extensive, [and] life-threatening[.]” R. 50.

Indeed, the ALJ afforded one of the consultative examiner’s opinions “great

weight,” R. 1918, even though his report suggests that he was unaware that plaintiff had

an aborted, emergency heart-surgery a mere few weeks prior, see R. 606 (detailing

plaintiff’s “chief complaint” and past medical history but only referencing the “surgery on

an infection in his valve done in November 2016”). In other words, the ALJ gave

importance to a medical source opinion that “lack[ed] necessary information,” Sagman

v. Comm’r of Soc. Sec., No. 20-cv-04257, 2021 WL 5831114, at *12 (S.D.N.Y. Dec. 8, 2021),

and relied on that opinion to conclude that plaintiff’s statements concerning his limiting

symptoms were unsupported. Therefore, the lack of documentation about—and medical

source opinion that accounted for—plaintiff’s second emergency heart surgery amounts

to a “clear gap” in the record which the ALJ was required to attempt to fill. See Lewis v.

Comm’r of Soc. Sec., No. 18-cv-06074, 2019 WL 5290936, at *6 (W.D.N.Y. Oct. 18, 2019)

(finding that there was an “obvious gap” in the record where the claimant testified that he

underwent back surgery, but the “ALJ mentioned the surgery only in passing,” and

“nevertheless concluded that the objective medical evidence [wa]s not consistent with

[the claimant’s] allegations of the severity of his symptoms of . . . pain”); see also Colucci

v. Acting Comm’r of Soc. Sec., No. 19-cv-01412, 2021 WL 1209713, at *5 (E.D.N.Y. Mar.

31, 2021) (“[T]he ALJ must seek additional evidence or clarification when a report from a

medical source contains a conflict or ambiguity, [or] lacks necessary information[.]”);

accord Mauro King v. Berryhill, 251 F. Supp. 3d 438, 444 (N.D.N.Y. 2017) (“A

consultative examiner’s opinion may not constitute substantial evidence where the

consultative examiner is not provided . . . the necessary background information.”).

In sum, the Court finds that a more adequately developed record with respect to

plaintiff’s second emergency heart surgery is necessary to afford plaintiff a “full and fair

hearing,” and remand is warranted for further development of the factual record.3

Michelle C. v. Comm’r of Soc. Sec., No. 23-cv-07144, 2024 WL 1706000, at *6 (S.D.N.Y.

Apr. 3, 2024), report and recommendation adopted, 2024 WL 1702127 (Apr. 18, 2024);

see also Tucker v. Bowen, No. 87-cv-03487, 1989 WL 10564, at *4 (E.D.N.Y. Feb. 2, 1989)

(“The ALJ’s affirmative duty to develop the record requires him to obtain the claimant’s

medical records and other relevant evidence where, as here, such evidence is necessary to

a fair determination of the claim.”).

B. Credibility Inquiry Standard

Remand is also warranted on the separate ground that the ALJ failed to apply the

correct legal standard when assessing plaintiff’s credibility. When determining a

3 To the extent the parties raise other disputes, including whether (1) the ALJ

properly evaluated the medical opinion evidence, Mot. 16–22; (2) whether the ALJ’s RFC

finding was supported by substantial evidence, Mot. 22–25; and (3) whether the ALJ

erred in relying on the vocational expert’s testimony, Mot. 25–29, the “ALJ’s failure to

develop the record is a threshold problem,” and thus the Court declines to address these

issues in the absence of a more fulsome factual record. See Santoro, 703 F. Supp. 3d at

390 (explaining that “the gap in the record le[ft] the [c]ourt unable to resolve” issues

raised by the parties, including “whether the ALJ’s RFC finding was supported by

substantial evidence” because that finding “was made on an incomplete record”).

claimant’s RFC, the ALJ “is required to take the claimant’s reports of pain and other

limitations into account.” Genier v. Astrue, 606 F.3d 46, 49 (2d Cir. 2010) (citing 20

C.F.R. § 416.929). The ALJ need not “accept the claimant’s subjective complaints without

question; [s]he may exercise discretion in weighing the credibility of the claimant’s

testimony in light of the other evidence in the record.” Id. SSA regulations provide for a

two-step process to assess the credibility of a claimant’s testimony. First, the ALJ

determines whether the claimant’s impairment “could reasonably be expected to produce

the symptoms alleged”; second, the ALJ determines whether and to what extent the

claimant’s reported symptoms “can reasonably be accepted as consistent with the

objective medical evidence and other evidence of record.” Colombia B.N. v. Comm’r of

Soc. Sec., No. 21-cv-10622, 2023 WL 358599, at *5–6 (S.D.N.Y. Jan. 23, 2023). If a

claimant provides testimony concerning his symptoms that “is not fully supported by

clinical evidence, the ALJ must consider additional factors in order to assess that

testimony.” Jaeckel v. Colvin, No. 13-cv-04270, 2015 WL 5316335, at *9 (E.D.N.Y. Sep.

11, 2025).

Specifically, the ALJ must consider the factors set forth in 20 C.F.R.

§ 404.1529(c)(3)(i)–(vii), including: (1) the claimant’s daily activities; (2) the location,

duration, frequency, and intensity of the pain; (3) precipitating and aggravating factors;

(4) the type, dosage, effectiveness, and side effects of medications taken to address the

pain; (5) the treatment, other than medication, that the claimant has received; (6) other

measures that the claimant uses to alleviate the pain; and (7) other factors concerning the

claimant’s limitations and restrictions as a result of the pain. See Meadors v. Astrue, 370

F. App’x 179, 184 n.1 (2d Cir. 2010) (summary order); see also Correale-Englehart v.

Astrue, 687 F. Supp. 2d 396, 435 (S.D.N.Y. 2010).

If, after considering the objective medical evidence and relevant credibility factors,

an ALJ finds that a claimant’s testimony is not credible, “[s]he must explain that decision

with sufficient specificity to permit a reviewing court to decide whether there are

legitimate reasons for the ALJ’s disbelief.” Romanelli v. Astrue, No. 11-cv-04908, 2013

WL 1232341, at *11 (E.D.N.Y. Mar. 26, 2013); see also Castel, 2020 WL 5775668, at *13

(“To the extent the ALJ determines that the claimant’s statements are not supported by

the medical record, however, the ALJ’s decision must include specific reasons for the

weight given to the individual’s symptoms, . . . and the reasons must be clearly

articulated[.]”). In other words, an ALJ must clearly articulate “the reasons for any

discounting of [a claimant’s] statements” concerning their symptoms. Castel, 2020 WL

5775668, at *20.

Although an ALJ is not required to “explicitly examine all seven [credibility]

factors,” an ALJ’s credibility determination must contain a sufficiently “thorough

explanation” such that a reviewing court may “glean” their rationale. Travis M. v. Comm’r

of Soc. Sec. Admin., No. 24-cv-07341, 2025 WL 2157840, at *9 (S.D.N.Y. July 30, 2025).

Still, an ALJ is “required to consider” relevant credibility factors listed in 20 C.F.R.

§ 404.1529(c)(3) when conducting a credibility inquiry, and her decision must “explain

how she balanced those factors.” Adesina v. Astrue, No. 12-cv-03184, 2014 WL 5380938,

at *13 (E.D.N.Y. Oct. 22, 2014) (“When conducting a credibility inquiry, the ALJ is

required to consider all of the factors listed in 20 C.F.R. § 404.1529(c)(3) and explain how

she balanced those factors.”); cf. Cichocki v. Astrue, 534 F. App’x 71, 76 (2d Cir. 2013)

(summary order) (concluding that the failure to discuss “those [credibility] factors not

relevant to [a claimant’s] credibility determination” did not require remand). Where an

ALJ “insufficiently applies the credibility factors” or where an ALJ’s credibility analysis

“fails to refer to or discuss the factors,” remand is appropriate. Travis, 2025 WL 2157840,

at *9; see also Monroe v. Astrue, No. 12-cv-01456, 2014 WL 3756351, at *6–7 (E.D.N.Y.

July 30, 2014).

Plaintiff argues that the ALJ erred at the second step of the credibility analysis

because she failed to address the credibility factors. Mot. 10. Plaintiff also argues that in

lieu of articulating specific reasons why she discounted plaintiff’s statements concerning

his symptoms, the ALJ provided mere conclusory statements in support of her decision.

See Mot. 12. Defendant does not address whether the ALJ erred in failing to discuss the

credibility factors. See Cross-Mot. 11. Instead, defendant argues that the ALJ “must only

identify record-based reasons for [her] conclusion” as to whether claimant’s allegations

about his symptoms were false or otherwise contradicted by the record. Cross-Mot. 11.

And in defendant’s view, the ALJ did so here by considering plaintiff’s “contemporaneous

reports to his doctors and his activities of daily living” in concluding that his allegations

concerning his disabling symptoms were contradicted by the record. Cross-Mot. 11.

The Court finds that the ALJ erred at the second step of the credibility analysis by

insufficiently applying and balancing the credibility factors. The ALJ concluded that

plaintiff’s “statements about the intensity, persistence, and limiting effects of his

symptoms, [were] inconsistent because they [we]re not fully supported by the medical

evidence.” R. 1916. In doing so, the ALJ was required to “weigh the credibility of

[plaintiff’s] testimony regarding the severity of [his] symptoms in light of [the] seven

[credibility] factors.” Peña v. Astrue, No. 08-cv-03304, 2011 WL 2847438, at *2 (E.D.N.Y.

June 22, 2011), report and recommendation adopted, 2011 WL 2837409 (July 13, 2011).

And to the extent that the ALJ did not expressly examine each factor, she was required to

at least examine and balance any relevant factors and provide a sufficiently thorough

explanation such that the Court could glean her rationale. See Cichocki, 534 F. App’x at

76.

The ALJ failed to do so here. At the beginning of her analysis, the ALJ stated that if

she found plaintiff’s statements concerning his pain or other symptoms were not

substantiated by objective medical evidence then she must “consider other evidence in

the record to determine if [plaintiff’s] symptoms limit the ability to do work-related

activities.” R. 1915. The ALJ then went on to recite plaintiff’s medical history and various

medical opinions in the record. See R. 1916–19. Nowhere in this discussion did the ALJ

explain how—or whether—this “other evidence in the record” corresponded with the

credibility factors set forth in 20 C.F.R. § 404.1529(c)(3). See R. 1915; see also Romanelli,

2013 WL 1232341, at *11 (“Here, while the ALJ recited various medical evidence,

including [the] [p]laintiff’s limited daily activities and [the] [p]laintiff’s description of

dizziness, headaches, and coughing, he provided no analysis as to how these items—or

any other 20 C.F.R. § 404.1529(c)(3) factors—led to his conclusory statement that [the]

[p]laintiff’s testimony concerning the intensity and limiting effects of her condition was

not credible.”); see also Adesina, 2014 WL 5380938, at *13 (concluding that the ALJ

“erred in exclusively relying upon her reading of objective medical evidence to reject [the]

[p]laintiff’s assertions regarding her symptoms,” because “[w]hen conducting a

credibility inquiry, the ALJ is required to consider all of the factors listed in 20 C.F.R.

§ 404.1529(c)(3)”); Simone v. Astrue, No. 08-cv-04884, 2009 WL 2992305, at *11

(E.D.N.Y. Sep. 16, 2009) (explaining that remand was required where the ALJ “did not

offer any analysis of the factors prescribed for evaluating subjective pain, and instead

relied simply on the lack of objective evidence to discredit [the] plaintiff[’s] claims

regarding his symptoms”).

Indeed, the only credibility factor that the ALJ expressly referenced in her analysis

was plaintiff’s daily activities of living. See R. 1916 (“The claimant’s allegations are also

not fully in line with the claimant’s reported activities of daily living.”). Aside from

tangential discussion about the frequency of certain of plaintiff’s reported symptoms and

medications he used to treat those symptoms, see R. 1917, the ALJ’s analysis was

otherwise devoid of specific reference to, or analysis of, the other credibility factors and

instead relied on plaintiff’s medical history and medical opinions in the record to support

the conclusion that plaintiff’s statements concerning the limiting effects of his symptoms

were not entirely credible. See R. 1916–19. But this analysis is inadequate because SSA

regulations recognize “the fact that an individual’s symptoms can sometimes suggest a

greater level of severity of impairment than can be shown by the objective medical

evidence alone.” Correale-Englehart, 687 F. Supp. 2d at 435 n.58. Thus, the purpose of

the credibility factors is to outline “the kinds of evidence that the adjudicator must

consider in addition to the objective medical evidence when assessing the credibility of an

individual’s statements.” Id.

Plaintiff’s case illustrates this point. During the March 2019 hearing, plaintiff

testified that following his heart surgeries he suffered from significant chest pain up to

around March 2018. See R. 32–34; Joint Stip. ¶ 48.4 Specifically, plaintiff testified that

the pain from the incision point “was at a 10” out of 10 severity. R. 33. Moreover, doctors

4 Defendant raises the point that plaintiff’s allegations of severe chest pain was “a

claim solely made during the March 2019 hearing[.]” Cross-Mot. 12. But this argument is

unavailing because (1) an ALJ “must consider the entire record,” when “evaluating the

intensity and persistence of the claimant’s symptoms,” Davis v. Colvin, No. 15-cv-01327,

2016 WL 5334648, at *3 (D. Conn. Sept. 21, 2016); and (2) the ALJ considered other

testimony from that hearing in making her credibility assessment—testimony from the

independent medical expert, Dr. Jilhewar, see R. 1918.

prescribed plaintiff oxycodone to treat discomfort he felt in the aftermath of the

procedure. Joint Stip. ¶ 12 n.20. Although this evidence could have suggested a more

severe level of impairment than indicated by plaintiff’s medical history, the Court cannot

discern how—or if—the ALJ weighed this evidence in determining plaintiff’s credibility in

light of the lack of analysis with respect to the credibility factors. See Simone, 2009 WL

2992305, at *11 (concluding that the ALJ “did not properly evaluate [the] plaintiff's

credibility” even where the ALJ “listed the factors given in 20 C.F.R. 404.1529(c)(3)”

because the ALJ “did not analyze those factors or incorporate them into his analysis”). In

other words, “[i]n making h[er] determination about plaintiff’s credibility, it is not clear

that the ALJ took into account the factors listed in 20 C.F.R. § 404.1529(c)(3) other than

plaintiff’s daily activities as the regulations and caselaw require.” Jaeckel, 2015 WL

5316335, at *11 (remanding where “the ALJ summarized plaintiff’s testimony, various

medical evidence, and some of plaintiff’s activities of daily living, [because] the ALJ did

not explain which factors, other than certain of [the] claimant’s admitted activities, he

evaluated in determining that [the] claimant’s statements concerning the intensity,

persistence and limiting effects of these symptoms [were] not credible”); see also Travis,

2025 WL 2157840, at *9 (“[M]erely reciting [p]laintiff’s medical history, even with a

limited review of the specified factors, falls short of a proper credibility analysis.”).

Defendant’s argument that substantial evidence supports the “ALJ’s conclusion

that [p]laintiff’s subjective claims were not consistent with the record,” Cross-Mot. 12,

misses the mark. Whether the ALJ considered and applied the 20 C.F.R. § 404.1529(c)(3)

factors relates to application of a legal standard. See Monroe, 2014 WL 3756351, at *7

(“By failing to consider and discuss all applicable factors set forth in 20 C.F.R.

§ 404.1529(c)(3) when making her credibility inquiry, the ALJ committed legal error.”);

Felder v. Astrue, No. 10-cv-05747, 2012 WL 3993594, at *15 (E.D.N.Y. Sept. 11, 2012)

(same); Jaeckel, 2015 WL 5316335, at *11 (same). Indeed, it may ultimately be the case

that substantial evidence supports the ALJ’s conclusion that plaintiff’s statements

concerning the limiting effects of his symptoms are not entirely credible. Still, on remand

the ALJ must reach that conclusion with sufficient consideration and reference to the

factors set forth by SSA regulations. See Travis, 2025 WL 2157840, at *11 (ordering

remand because the ALJ failed to “provide an adequate explanation for discounting [the]

[p]laintiff’s subjective testimony,” and noting that it was “possible that the ALJ would

reach the same conclusion on remand, but any new credibility determination should

address [the] [p]laintiff’s testimony more specifically with reference to the factors

outlined in 20 C.F.R. § 404.1529(c)(3)”); accord Johnson v. Bowen, 817 F.2d 983, 986

(2d Cir. 1987) (“Where there is a reasonable basis [to] doubt whether the ALJ applied

correct legal principles, application of the substantial evidence standard to uphold a

finding of no disability creates an unacceptable risk that a claimant will be deprived of the

right to have h[is] disability determination made according to the correct legal

principles.”).

Finally, the Court notes that to the extent the ALJ considered relevant credibility

factors in weighing plaintiff’s statements concerning his symptoms, remand is still

warranted because the ALJ’s decision failed to explain how she balanced those factors.

See Monroe, 2014 WL 3756351, at *6 (ordering remand where the ALJ “consider[ed] [the]

[p]laintiff’s daily activities, some of his pain and symptoms, and the side effects of his

medications,” because the ALJ “failed to indicate how she balanced those factors”);

Simone, 2009 WL 2992305, at * 11 (ordering remand even where the “ALJ properly listed

the factors given in 20 C.F.R. 404.1529(c)(3)” because the ALJ “did not identify what facts

he found to be significant, indicate how he balanced the various factors, or specify which

of [the] plaintiff’s alleged symptoms he found to be not credible[,] [but] [i]nstead . . .

devoted his analysis to his erroneous conclusion that there was a lack of objective evidence

supporting plaintiff’s claims”).

In short, the record is unclear as to whether the ALJ “meaningfully consider[ed] the

full range of § 404.1529(c)(3) factors.” Adesina, 2014 WL 5380938, at *13. Therefore,

remand is warranted. See Grosse v. Comm’r of Soc. Sec., No. 08-cv-04137, 2011 WL

128565, at *5 (E.D.N.Y. Jan. 14, 2011) (finding that the ALJ committed legal error and

ordering remand because the ALJ failed to consider credibility factors two through

seven). On remand, to the extent that the ALJ “determines that any of claimant’s

statements are inconsistent with medical evidence in the record, the ALJ should specify

the statements and the evidence in the record, and explain why [s]he chooses to discredit

the statements with reference to the applicable regulatory factors.” Jaeckel, 2015 WL

5316335, at *11; see also Adesina, 2014 WL 5380938, at *14 (“On remand, the ALJ must

explicitly discuss each of the seven factors before rejecting [the] [p]laintiff’s credibility.”).

CONCLUSION

For the reasons stated above, plaintiff’s motion for judgment on the pleadings is

GRANTED, and the Commissioner’s cross-motion is DENIED. This action is

REMANDED for further proceedings consistent with this Order. The Clerk of Court is

respectfully directed to enter judgment and close this case.

SO ORDERED.

/s/ Natasha C. Merle

NATASHA C. MERLE

United States District Judge

Dated: February 20, 2026

Brooklyn, New York