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Dawn W. v. Comm'r of Soc. Sec.

United States District Court, W.D. New York
Jan 9, 2023
650 F. Supp. 3d 53 (W.D.N.Y. 2023)

Opinion

6:21-CV-06110 EAW

2023-01-09

DAWN W., Plaintiff, v. COMMISSIONER OF SOCIAL SECURITY, Defendant.

Jeanne Elizabeth Murray, Kenneth R. Hiller, Samantha J. Ventura, Law Offices of Kenneth Hiller, PLLC, Amherst, NY, for Plaintiff. Jason Parkerson Peck, Office of the General Counsel Office of General Counsel, Baltimore, MD, Kathryn L. Smith, U.S. Attorney's Office, Rochester, NY, for Defendant.


Jeanne Elizabeth Murray, Kenneth R. Hiller, Samantha J. Ventura, Law Offices of Kenneth Hiller, PLLC, Amherst, NY, for Plaintiff. Jason Parkerson Peck, Office of the General Counsel Office of General Counsel, Baltimore, MD, Kathryn L. Smith, U.S. Attorney's Office, Rochester, NY, for Defendant.

DECISION AND ORDER

ELIZABETH A. WOLFORD, Chief Judge

INTRODUCTION

Represented by counsel, Plaintiff Dawn W. ("Plaintiff") brings this action pursuant to Title II of the Social Security Act (the "Act"), seeking review of the final decision of the Commissioner of Social Security (the "Commissioner," or "Defendant") denying her application for disability insurance benefits ("DIB"). (Dkt. 1). This Court has jurisdiction over the matter pursuant to 42 U.S.C. § 405(g). Presently before the Court are the parties' cross-motions for judgment on the pleadings pursuant to Rule 12(c) of the Federal Rules of Civil Procedure (Dkt. 6; Dkt. 7), and Plaintiff's reply (Dkt. 9). For the reasons discussed below, the Commissioner's motion (Dkt. 7) is granted, and Plaintiff's motion (Dkt. 6) is denied.

BACKGROUND

Plaintiff protectively filed her application for DIB on June 12, 2018. (Dkt. 5 at 16, 93). In her application, Plaintiff alleged disability beginning on August 1, 2017, due to depression and migraines. (Id. at 16, 80). Plaintiff's application was initially denied on August 21, 2018. (Id. at 16, 96-107). A telephone hearing was held before administrative law judge ("ALJ") Paul F. Kelly on May 13, 2020. (Id. at 16, 39-78). On July 16, 2020, the ALJ issued an unfavorable decision. (Id. at 13-33). Plaintiff requested Appeals Council review; her request was denied on December 10, 2020, making the ALJ's determination the Commissioner's final decision. (Id. at 5-10). This action followed.

When referencing the page number(s) of docket citations in this Decision and Order, the Court will cite to the CM/ECF-generated page numbers that appear in the upper righthand corner of each document.

LEGAL STANDARD

I. District Court Review

"In reviewing a final decision of the [Social Security Administration ("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) (quotation omitted); see also 42 U.S.C. § 405(g). The Act holds that a decision by the Commissioner is "conclusive" if it is supported by substantial evidence. 42 U.S.C. § 405(g). "Substantial evidence means more than a mere scintilla. It means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Moran v. Astrue, 569 F.3d 108, 112 (2d Cir. 2009) (quotation omitted). It is not the Court's function to "determine de novo whether [the claimant] is disabled." Schaal v. Apfel, 134 F.3d 496, 501 (2d Cir. 1998) (quotation omitted); see also Wagner v. Sec'y of Health & Human Servs., 906 F.2d 856, 860 (2d Cir. 1990) (holding that review of the Secretary's decision is not de novo and that the Secretary's findings are conclusive if supported by substantial evidence). However, "[t]he deferential standard of review for substantial evidence does not apply to the Commissioner's conclusions of law." Byam v. Barnhart, 336 F.3d 172, 179 (2d Cir. 2003) (citing Townley v. Heckler, 748 F.2d 109, 112 (2d Cir. 1984)). II. Disability Determination

An ALJ follows a five-step sequential evaluation to determine whether a claimant is disabled within the meaning of the Act. See Bowen v. City of New York, 476 U.S. 467, 470-71, 106 S.Ct. 2022, 90 L.Ed.2d 462 (1986). At step one, the ALJ determines whether the claimant is engaged in substantial gainful work activity. See 20 C.F.R. § 404.1520(b). If so, the claimant is not disabled. If not, the ALJ proceeds to step two and determines whether the claimant has an impairment, or combination of impairments, that is "severe" within the meaning of the Act, in that it imposes significant restrictions on the claimant's ability to perform basic work activities. Id. § 404.1520(c). If the claimant does not have a severe impairment or combination of impairments, the analysis concludes with a finding of "not disabled." If the claimant does have at least one severe impairment, the ALJ continues to step three.

At step three, the ALJ examines whether a claimant's impairment meets or medically equals the criteria of a listed impairment in Appendix 1 of Subpart P of Regulation No. 4 (the "Listings"). Id. § 404.1520(d). If the impairment meets or medically equals the criteria of a Listing and meets the durational requirement (id. § 404.1509), the claimant is disabled. If not, the ALJ determines the claimant's residual functional capacity ("RFC"), which is the ability to perform physical or mental work activities on a sustained basis, notwithstanding limitations for the collective impairments. See id. § 404.1520(e).

The ALJ then proceeds to step four and determines whether the claimant's RFC permits the claimant to perform the requirements of his or her past relevant work. Id. § 404.1520(f). If the claimant can perform such requirements, then he or she is not disabled. If he or she cannot, the analysis proceeds to the fifth and final step, wherein the burden shifts to the Commissioner to show that the claimant is not disabled. Id. § 404.1520(g). To do so, the Commissioner must present evidence to demonstrate that the claimant "retains a residual functional capacity to perform alternative substantial gainful work which exists in the national economy" in light of the claimant's age, education, and work experience. Rosa v. Callahan, 168 F.3d 72, 77 (2d Cir. 1999) (quotation omitted); see also 20 C.F.R. § 404.1560(c).

DISCUSSION

I. The ALJ's Decision

In determining whether Plaintiff was disabled, the ALJ applied the five-step sequential evaluation set forth in 20 C.F.R. § 404.1520. Initially, the ALJ determined that Plaintiff last met the insured status requirements of the Act on June 30, 2022. (Dkt. 5 at 18). At step one, the ALJ determined that Plaintiff had not engaged in substantial gainful work activity since August 1, 2017, the alleged onset date. (Id.).

At step two, the ALJ found that Plaintiff suffered from the severe impairments of: "depressive disorder; posttraumatic stress disorder ('PTSD'); generalized anxiety disorder ('GAD'); migraine headaches; lumbar degenerative disc disease ('DDD') status-post May 9, 2019 lumbar fusion surgery at L5-S1; cervical DDD; and obesity." (Id. at 19). The ALJ further found that Plaintiff's medically determinable impairments of history of a total left knee replacement and high-grade partial thickness tear of the biceps tendon at the right elbow were non-severe. (Id. at 19-20).

At step three, the ALJ found that Plaintiff did not have an impairment or combination of impairments that met or medically equaled the severity of any Listing. (Id. at 20). The ALJ particularly considered the criteria of Listings 1.04, 12.04, 12.06, and 12.15 in reaching his conclusion, as well as considering the effect of Plaintiff's obesity as required by Social Security Ruling ("SSR") 19-2p. (Id. at 20-23).

Before proceeding to step four, the ALJ determined that Plaintiff retained the RFC to perform light work as defined in 20 C.F.R. § 404.1567(b), except that Plaintiff:

is able to lift up to 20 pounds occasionally and 10 pounds frequently, stand and walk for about six hours, and sit for up to six hours in an eight-hour workday with normal breaks; never climb ladders, ropes or scaffolds; occasionally climb ramps and stairs, balance, stoop, kneel, crouch, and crawl. The claimant should avoid excessive noise; claimant should avoid excessive vibration; claimant must avoid all exposure to unprotected heights and dangerous machinery; is limited to simple, routine tasks; limited to low stress work, which is defined as involving only occasional decision-making or occasional changes in work setting; with only occasional interaction with the public or coworkers, and contact with others must be brief and superficial in nature.
(Id. at 23). At step four, the ALJ found that Plaintiff was unable to perform any past relevant work. (Id. at 31).

At step five, the ALJ relied on the testimony of a vocational expert ("VE") to conclude that, considering Plaintiff's age, education, work experience, and RFC, there were jobs that exist in significant numbers in the national economy that Plaintiff could perform, including the representative occupations of laundry worker, cafeteria attendant, and mail clerk. (Id. at 31-32). Accordingly, the ALJ found that Plaintiff was not disabled as defined in the Act. (Id. at 32-33).

II. The Commissioner's Determination is Supported by Substantial Evidence and Free from Legal Error

Plaintiff asks the Court to reverse or, in the alternative, to remand this matter to the Commissioner, arguing that the RFC is not supported by substantial evidence. In support of this argument, Plaintiff provides a laundry list of medical opinions she contends the ALJ rejected, concluding that he therefore relied on his own lay interpretation of the record. (Dkt. 6-1 at 13-18). Plaintiff takes issue specifically with the ALJ's assessment of opinions offered by Adam Brownfeld, Ph.D., A. Chapman, Psy.D., C. Krist, D.O., Harbinder Toor, M.D., and John Schubmehl, M.D. (Id.). The Court has considered Plaintiff's arguments and, for the reasons discussed below, finds that they are without merit, and that the Commissioner's decision is supported by substantial evidence in the record.

In deciding a disability claim, an ALJ is tasked with "weigh[ing] all of the evidence available to make an RFC finding that [is] consistent with the record as a whole." Matta v. Astrue, 508 F. App'x 53, 56 (2d Cir. 2013). It is well-settled that an ALJ's conclusion need not "perfectly correspond with any of the opinions of medical sources cited in his decision." Id. However, an ALJ is not a medical professional, and "is not qualified to assess a claimant's RFC on the basis of bare medical findings." Ortiz v. Colvin, 298 F. Supp. 3d 581, 586 (W.D.N.Y. 2018) (quotation omitted). In other words:

An ALJ is prohibited from 'playing doctor' in the sense that 'an ALJ may not substitute his own judgment for competent medical opinion . . . .' This rule is most often employed in the context of the RFC determination when the claimant argues either that the RFC is not
supported by substantial evidence or that the ALJ has erred by failing to develop the record with a medical opinion on the RFC.
Quinto v. Berryhill, No. 3:17-cv-00024 (JCH), 2017 WL 6017931, at *12 (D. Conn. Dec. 1, 2017) (citations omitted). "[A]s a result[,] an ALJ's determination of RFC without a medical advisor's assessment is not supported by substantial evidence." Dennis v. Colvin, 195 F. Supp. 3d 469, 474 (W.D.N.Y. 2016) (quotation and citation omitted). However, at bottom, "[a]n RFC finding is administrative in nature, not medical, and its determination is within the province of the ALJ, as the Commissioner's regulations make clear." Curry v. Comm'r of Soc. Sec., 855 F. App'x 46, 48 n.3 (2d Cir. 2021).

This is not a case where the ALJ fashioned an RFC without obtaining any medical opinion evidence. To the contrary, the record includes several medical opinions which the ALJ considered, including opinions offered by Dr. Chapman, Dr. Brownfeld, Dr. Krist, Dr. Toor, and Dr. Schubmehl. (See Dkt. 5 at 29-31). As explained above, simply because the ALJ declined to adopt any one opinion in its entirety does not undermine the RFC, since an RFC is not required to "perfectly correspond with any of the opinions of medical sources cited in his decision." Matta, 508 F. App'x at 56. Accordingly, to the extent Plaintiff contends that the RFC is not supported by substantial evidence because the ALJ declined to adopt the opinion offered by any one medical professional, any such argument is misplaced.

The Court turns first to Plaintiff's arguments relating to the ALJ's assessment of her mental limitations, including the opinions offered by Dr. Brownfeld and Dr. Chapman. Dr. Brownfeld examined Plaintiff on August 1, 2018, and found the following:

No evidence of limitation in understanding, remembering, or applying simple directions and instructions, using reason and judgment to make work-related decisions, interacting adequately with supervisors, coworkers, and the public, maintaining personal hygiene and appropriate attire, and being aware of normal hazards and taking appropriate precautions. She is mildly limited in sustaining concentration and performing a task at a consistent pace, sustaining an ordinary routine and regular attendance at work, and applying complex directions and instructions. She is markedly limited in regulating emotions, controlling behavior, and maintaining well-being.
(See Dkt. 5 at 29, 577-80). The ALJ found Dr. Brownfeld's opinion that Plaintiff had marked limitations to be "not persuasive," explaining that "[i]t is not supported by Dr. Brownfeld's examination of [Plaintiff], which revealed relatively minimal objective findings, and it is inconsistent with the overall evidence of record." (Id. at 29). Plaintiff disagrees with the ALJ's characterization of Dr. Brownfeld's findings as "relatively minimal," because Dr. Brownfeld's examination showed impaired attention and concentration, as well as depressed affect and dysthymic mood. (See Dkt. 6-1 at 15).

Plaintiff has failed to demonstrate how the ALJ erred in his assessment of Dr. Brownfeld's opinion, or that the RFC is not otherwise supported by substantial evidence. The RFC—which limits Plaintiff to simple, low-stress work and reduced contact with others—is consistent with Dr. Brownfeld's examination findings, his opinion that Plaintiff has mostly either no or mild limitations, and other evidence in the record. As explained above, the ALJ is tasked with "weigh[ing] all of the evidence available to make an RFC finding that [is] consistent with the record as a whole." Matta, 508 F. App'x at 56; see also Trepanier v. Comm'r of Soc. Sec., 752 F. App'x 75, 79 (2d Cir. 2018) ("Even where the ALJ's determination does not perfectly correspond with any of the opinions of medical sources cited in his decision, however, the ALJ was entitled to weigh all of the evidence available to make a residual functional capacity finding that was consistent with the record as a whole."). Plaintiff has failed to demonstrate that she is entitled to additional mental limitations beyond those included in the RFC.

Further, Plaintiff's argument amounts to no more than a disagreement with the ALJ's assessment of Dr. Brownfeld's opinion. The Court has reviewed Dr. Brownfeld's examination of Plaintiff and, although he found that her attention and concentration and memory skills were impaired, he also found that Plaintiff was cooperative, and that her presentation was adequate; her appearance, speech, and thought processes were normal; she was well-oriented; she could count and do simple calculations; and has average intellectual functioning, as well as good insight and judgment (Dkt. 5 at 578-79), and the Court can discern how the ALJ concluded that Dr. Brownfeld's examination findings were relatively minimal. Accordingly, remand is not required on this basis.

Plaintiff next argues that the ALJ found Dr. Chapman's opinion persuasive, which is inconsistent with her evaluation of Dr. Brownfeld's opinion, since Dr. Chapman's opinion is largely based on Dr. Brownfeld's opinion. Dr. Chapman, the state agency medical consultant, reviewed Plaintiff's record and found that she had moderate limitations for understanding, remembering, or applying information, interacting with others, and concentrating, persisting, or maintaining pace, and mild limitations in her ability to adapt or manage herself. (Dkt. 5 at 84). Dr. Chapman further found that Plaintiff had moderate limitations in the following areas: understand, remember, and carry out detailed instructions; maintain attention and concentration for extended periods; perform activities within a schedule, maintain regular attendance, be punctual; work in coordination with or in proximity to others without being distracted by them; complete a normal workday and workweek; accept instructions and respond appropriately to criticism from supervisors; and get along with coworkers or peers (id. at 29, 88-89), concluding that Plaintiff retained the ability to perform the basic mental demands of unskilled work (id. at 90).

The ALJ explained that he found Dr. Chapman's opinion to be "persuasive, except for mild limitations in adapting or managing oneself and the moderate limitations in getting along with supervisors," including because Dr. Chapman "reviewed the records and provided a detailed rationale for the opinion," and the opinion was "generally consistent with the overall evidence of record . . . ." (Id. at 29). Like Plaintiff's arguments pertaining to Dr. Brownfeld's opinion, Plaintiff has failed to demonstrate how Dr. Chapman's opinion relating to Plaintiff's functioning requires further limitations beyond those already included in the RFC. The RFC limits Plaintiff to simple, unskilled work with limited interaction with others, which is consistent with the mild and moderate limitations assessed by Dr. Chapman. See, e.g., Washburn v. Colvin, 286 F. Supp. 3d 561, 566 (W.D.N.Y. 2017) ("It is well settled that a limitation to unskilled work sufficiently accounts for moderate limitations in work-related functioning[.]"). As to Plaintiff's contention that the ALJ's assessment of Dr. Brownfeld's and Dr. Chapman's opinions is inconsistent, Dr. Brownfeld assessed some marked limitations, whereas Dr. Chapman assessed only some moderate limitations, and therefore the ALJ's finding Dr. Chapman's opinion to be more persuasive is not inconsistent with his assessment of Dr. Brownfeld's opinion.

Plaintiff does not make any specific argument as to the ALJ's assessment of the opinion offered by Ryan Houghtalen, N.P. and/or Dr. Schubmehl with respect to her mental limitations, but these providers completed a mental medical source statement on May 17, 2020. (See Dkt. 5 at 1150-52). Plaintiff would be off task for more than 20 percent of the workday, and absent four or more days per month. (Id. at 1152). Plaintiff would be precluded from performing the following tasks for 11 to 20 percent of the workday: maintain regular attendance and be punctual; sustain an ordinary routine without special supervision; complete a normal workday and workweek; perform at a consistent pace without an unreasonable number and length of rest periods; accept instructions and respond appropriately to criticism from supervisors; and deal with normal work stress. (Id. at 1151). Plaintiff would be precluded from performing the following tasks for less than 10 percent of the workday: maintain attention for two-hour segments; work in coordination with or proximity to others; make simple work-related decisions; get along with coworkers or peers; and respond appropriately to changes in a routine work setting. (Id.).

The medical source statement is signed only by N.P. Houghtalen (see Dkt. 5 at 1152), but the written determination states that the opinion was given by "Dr. Schubmehl or Mr. Houghtalen" (id. at 30).

The ALJ found that this opinion was "not persuasive," offering the following explanation:

Dr. Schubmehl's records do not support these limitations, particularly the time off-task, absences, and limitations of 11% to 20% of the workday. It is also generally inconsistent with the overall evidence of record. In particular, the overall evidence of record documents relatively routine and conservative treatment during the period at issue, with relatively unremarkable mental status examinations with her treating psychiatrist. Further, there are no documented emergency department visits or inpatient hospitalizations during the period at issue, and as noted in relation to her physical impairments, there are periods where the claimant reported feeling "amazing," including daily exercising including a Cross Fit regimen, spending time with her grandson, planning a trip to Utah with her daughter, and her return to work. In addition, the findings at the psychological consultative examination were relatively unremarkable.
(Id. at 30).

Plaintiff does not offer any specific argument as to how the ALJ erred in assessing Dr. Schubmehl's opinion, or explain how these limitations are not consistent with the RFC. The ALJ provided a detailed explanation as to why he rejected certain portions of the opinion, and the remainder of the limitations assessed are reflected in the RFC, which requires simple, unskilled work with limited interaction with others. For those reasons, the Court finds no error in the ALJ's assessment of the mental RFC, which is supported by the record.

Plaintiff next challenges the ALJ's assessment of the various physical opinions in the record, including the opinions offered by Dr. Krist and Dr. Toor. (Dkt. 6-1 at 16). Plaintiff contends that the ALJ "reject[ed] every single one," and that by doing so he relied on his own interpretation of the medical record, and that there is no functional assessment showing that Plaintiff can perform the exertional demands of light work. (Id.). Plaintiff further argues that the RFC includes no limitation as to Plaintiff's use of her cervical spine or her right arm, which is inconsistent with the medical evidence, and that the ALJ should have obtained additional opinion evidence. (Id. at 17).

Plaintiff sustained the lumbar and cervical impairments following her application for disability benefits. (See Dkt. 5 at 25-26, 46-47). Accordingly, as noted by the ALJ, several of the opinions in the record—including the opinions offered in 2018 by Dr. Toor and Dr. Krist—pre-date Plaintiff's lumbar and cervical impairments and Plaintiff's lumbar surgery. Dr. Toor examined Plaintiff on August 1, 2018, and opined that Plaintiff's migraine headaches can interfere with her routine, with no other medical limitations suggested by his examination. (Id. at 582-85). The ALJ found that Dr. Toor's opinion was persuasive "insofar as it relates to her impairments at the time of this evaluation," but further noted that Plaintiff "subsequently developed a lumbar and cervical spine herniation," which was not accounted for by Dr. Toor. (Id. at 30). Dr. Krist opined in August 2018 that Plaintiff had no physical limitations, except that she should avoid concentrated exposure to noise. (Id. at 86-87). The ALJ found that this opinion was not persuasive, given that Dr. Krist "did not have the opportunity to review the subsequent evidence of record, which documents her lumbar and cervical spine impairments that started after Dr. Krist performed this review," but further found that Dr. Krist's assessment that Plaintiff should avoid concentrated exposure to noise was "consistent with the overall evidence of record for the migraine headaches." (Id. at 29-30). Plaintiff offers no meaningful argument as to why the ALJ's assessment of these opinions—which the ALJ largely credited, with the exception of correctly noting that they do not reflect Plaintiff's subsequent lumbar and cervical impairments—is not supported by the record. Rather, the limitations assessed by both Dr. Toor and Dr. Krist are included in the RFC, including that Plaintiff must avoid excessive noise and vibration, and must avoid all exposure to unprotected heights and dangerous machinery.

On July 26, 2019, following Plaintiff's lumbar surgery in May 2019, Sara Brandel, PA-C, opined that Plaintiff was "stable from a neurosurgical standpoint to drive long periods of time," and also that she should stay within a ten-pound weight restriction under three months post-surgery. (Id. at 945). The ALJ found this opinion "not persuasive," including because PA Brandel provided the opinion shortly after the May 2019 lumbar fusion surgery, and she limited the restriction to three months. (Id. at 30). Given that PA Brandel's opinion plainly was meant to be limited to Plaintiff's surgical recovery period, the ALJ's assessment was proper. See, e.g., Ortiz, 298 F. Supp. 3d at 592 (ALJ's affording "little weight" to nurse's post-surgical assessment of the plaintiff's functioning was "reasonable," given that the nurse's opinion "was clearly limited to the period during which [the plaintiff] was recovering from surgery"). The ALJ also found that PA Brandel's opinion was not supported by contemporaneous treatment records containing documentation of Plaintiff's subjective reports of feeling "amazing," with no pain or limitations in her lumbar spine (see Dkt. 5 at 30-31) which, as noted below, the ALJ discussed at length in the written determination.

In addition to considering the opinion evidence in arriving at the physical RFC, the ALJ also discussed at length Plaintiff's medical records relating to her lumbar and cervical impairments, which was proper. See, e.g., Dana Lynn A. v. Comm'r of Soc. Sec., No. 20-CV-00968-MJR, 2021 WL 5410495, at *4 (W.D.N.Y. Nov. 19, 2021) (explaining that "the ALJ did not draw medical conclusions; instead, and pursuant to his statutory authority, the ALJ considered the medical and other evidence in the record in its totality to reach an RFC determination"). For example, as to Plaintiff's lumbar impairment, the ALJ explained that following Plaintiff's surgery in May 2019, other than experiencing dizziness as a result of either a urinary tract infection or/and her Valium prescription, Plaintiff's physical examinations were unremarkable, and PA Brandel noted that Plaintiff was doing "extremely well." (Id. at 25-26). In addition, Angel N. Boev, M.D., who performed Plaintiff's lumbar surgery, noted in September 2019 that Plaintiff reported she was feeling "amazing," as well as that Plaintiff was able to pick up her grandson, was working out, and back to working fulltime, concluding that Plaintiff had "healed beautifully from a surgical standpoint." (Id. at 26; see, e.g., id. at 845 (on September 10, 2019, at Plaintiff's three-month fusion follow-up appointment, noting that Plaintiff "feels amazing," and that after treating her urinary tract infection she has "recovered beautifully," that Plaintiff was "ecstatic," and had "healed beautifully," and could be seen "on an as needed basis," given that Plaintiff reported that she "doesn't need us or physical therapy at this point")). The ALJ concluded that "the overall evidence of record substantiates relatively minimal objective findings after the claimant sought treatment for the lumbar spine in January 2019," including that Plaintiff experienced a significant benefit after her May 2019 surgery, other than a brief period of dizziness and altered mental status allegedly caused by her Valium prescription. (Id.). As to the RFC, the ALJ explained that he "fully accounted for the lumbar spine impairment and obesity by limiting her to light exertion, which would limit her lifting, carrying, pushing and/or pulling to ten pounds frequently and twenty pounds occasionally. Further, the undersigned has included limitations to occasional postural activities except no ladders, ropes or scaffolds, and the need to avoid excessive vibration and noise and all exposure to unprotected heights and dangerous machinery." (Id.). Based on this discussion, it is clear to the Court how the ALJ arrived at the physical RFC.

As to Plaintiff's cervical impairment, the ALJ explained that the record documented no treatment for that condition until January 2020. (Id. at 26). The ALJ discussed at length Plaintiff's reports of pain, moderate osteophyte formation, as well as some abnormal findings on physical examinations. (Id.). The ALJ explained that "[a]lthough Dr. Boev scheduled an [anterior cervical discectomy] procedure for late March 2020, it is notable that the objective findings generally revealed relatively minimal neurologic deficits after she initiated treatment for this condition in January 2020," which were accounted for by the RFC for light work limiting Plaintiff's lifting, carrying, pushing and/or pulling to ten pounds frequently and twenty pounds occasionally, as well as limitations to occasional postural activities. (Id. at 27; see also id. at 1109-10 (on March 11, 2020, at visit to Rochester General Hospital for tremors, physical examination by Richard Paulis, M.D., revealing normal range of motion, including full range of motion in the cervical spine, and neurological examination showing "grossly intact" sensation, normal strength in the bilateral upper extremities, with flexion and extension of wrists, flexion of elbows, abduction of shoulders, and grip strength equal bilaterally)). Although Plaintiff notes her complaints relating to neck and arm pain she experienced (see Dkt. 6-1 at 16), the ALJ is not required to accept a claimant's subjective reports of pain, see, e.g., Genier v. Astrue, 606 F.3d 46, 49 (2d Cir. 2010) ("When determining a claimant's RFC, the ALJ is required to take the claimant's reports of pain and other limitations into account . . . but is not required to accept the claimant's subjective complaints without question; he may exercise discretion in weighing the credibility of the claimant's testimony in light of the other evidence in the record" (citations omitted)). Here, the written determination makes clear that the ALJ did consider Plaintiff's subjective reports of pain (see Dkt. 5 at 26-27), but nonetheless discredited these complaints based on other evidence in the record.

The ALJ's written determination, which spans 18 pages in length, adequately discusses each of the medical opinions in the record, and explains how he assessed the RFC. Plaintiff had ample opportunity to present evidence demonstrating that she requires additional limitations, including because the ALJ left the record open following the administrative hearing so that Plaintiff could submit additional medical documentation. (See, e.g., Dkt. 5 at 16, 48-49); Johnson v. Comm'r of Soc. Sec., No. 1:16-cv-00631-MAT, 2018 WL 1428251, at *5 (W.D.N.Y. Mar. 22, 2018) ("Where an ALJ becomes aware during the hearing that there may be additional medical records, he may satisfy his duty to develop the record by holding the hearing open to permit submission of additional records."). Because Plaintiff has failed to offer evidence demonstrating that she is entitled to additional mental or physical limitations beyond those already included in the RFC, remand is not required.

CONCLUSION

For the foregoing reasons, the Commissioner's motion for judgment on the pleadings (Dkt. 7) is granted, and Plaintiff's motion for judgment on the pleadings (Dkt. 6) is denied.

SO ORDERED.


Summaries of

Dawn W. v. Comm'r of Soc. Sec.

United States District Court, W.D. New York
Jan 9, 2023
650 F. Supp. 3d 53 (W.D.N.Y. 2023)
Case details for

Dawn W. v. Comm'r of Soc. Sec.

Case Details

Full title:DAWN W., Plaintiff, v. COMMISSIONER OF SOCIAL SECURITY, Defendant.

Court:United States District Court, W.D. New York

Date published: Jan 9, 2023

Citations

650 F. Supp. 3d 53 (W.D.N.Y. 2023)